Provider Tax ID

First Name

Last Name

Practice Name

Address

City

State

Zip

Phone Number

User Name

Password

Confirm Password

Must be 12 or more characters in length.
Must contain the following 4 types of characters:
- Upper Case (i.e. ABCD)
- Lower Case (i.e. abcd)
- Numeric (i.e. 0-9)
- Special Character What is this?