Department of Consumer Affairs Physician Assistant Board

Address/Name Changes

Reporting Your Address of Record to the Board

Title 16, California Code of Regulations, Section 1399.511, requires licensees to report any changes of mailing address within thirty (30) days of the change. You may have an alternate address, such as a post office box or place of business as your address of record. If you use a post office box as your address of record, you must also provide a confidential street address which will not be disclosed to the public.

The address of record is disclosed to the public and is available on the Board website under Verify a License. All Board mailings will be sent to your address of record and disclosed to the all individuals upon request.

1399.511. Notice of Change of Address.
(a) Each person or approved program holding a license, approval or interim approval and each person or program who has an application on file with the board or the committee shall notify the committee at its office of any and all changes of mailing address within thirty (30) calendar days after each change, giving both the old and new address.
(b) If an address reported to the committee is a post office box, the licensee shall also provide the committee with a street address, but he or she may request that the second address not be disclosed to the public.

How to Report your Address/Name Change

You may submit your change your address online by selecting the Online Address Change Form below or download the Change of Address Change form and mail it to the Board office.

You may change your name by downloading the Change of Name form and mailing it to the Board office with the appropriate fee.

You may request a duplicate license by downloading the Request for Duplicate License form and mailing it to the Board office with the appropriate fee.

Name changes and requests for duplicate wall/wallet licenses may not be submitted online and must be submitted to the Board by completing the required form below.