Provider Information

First Name fname); ?> First Name is required and must be a string.

Middle Name mname); ?> Must be a string.

Last Name lname); ?> Last Name is required and must be a string.

Email / Username username); ?>

User Role

Address

Practice office address

Address 1 street); ?> Street is required and must be a string.

Address 2 streetb); ?> Street is required and must be a string.

City city); ?> Must be a string.

State state); ?> Must be a string.

Zipcode zip); ?> Zipcode is required.

Phone phone); ?>

Email email); ?> Email is required with email format.

License state_license_number); ?> License is required with one letter and numbers.

Preferred Lab (Actual - name); ?>)

info === "ChE.forAuthorization-Administrator" || $providerData->info === "ChE.forAuthorization-Provider" || $providerData->info === "ChE.forAuthorization-Staff") && $providerData->authorized == 0 && $providerData->active == 0): ?>

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Provider Details

fname . " " . $providerData->lname); ?>

Provider Information

User Role

Address