Pennsylvania Society of Physician Assistants
Membership Application
Please complete the following form to register for a PSPA membership. Fields marked with an * are required. After completing the form please click the 'Next' button to proceed to the secure credit card processing page.
User Information:
First Name
*
Middle Name
Last Name
*
Home Address Information:
Home Address1
*
Home Address2
Home City
*
Home State
*
Home Zip Code
*
Home Phone
*
Work Address1
Work Address2
Work City
Work State
Work Zip Code
Work Phone
Fax
E-mail
*
Confirm E-mail
*
Please click here if you DO NOT want to be included in our online directory. Please note that this directory is only available other PSPA logged into the website.
County
*
Home region
Region 1
Region 2
Region 3
Region 4
Region 5
Region 6
Region 7
Region 8
Region 9
Preferred education region
Region 1
Region 2
Region 3
Region 4
Region 5
Region 6
Region 7
Region 8
Region 9
Senate District
House District
Membership Category
Fellow $100 (AAPA member practicing and/or residing in PA)
Affiliate $100 (Non-AAPA member practicing and/or residing in PA)
Sustaining $60 (PA not practicing in PA, or other health professional)
Associate $170 (Hospital, Insurance Co. or Group Practice)
Solo Practice Physician $100
Student $30 one year
Student $50.00 two years
Non-PA Student $15 (individual interested in exploring the Profession
PA Program
Year Of Graduation
Current AAPA#
Current NCCPA#
Medical Board Number
Osteopathic Board#
Pratice Setting
Pratice Speciality