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NCMB Forum Disciplinary Report – Aug-Nov, 2018

NCMB Forum Disciplinary Report Date: August-November 2018 December 2018 Digital Edition Name/license #/location Date of action Cause of action Board action ANNULMENTS NONE SUMMARY SUSPENSIONS NONE REVOCATIONS KESSEL, John Woodruff, MD (000036206)

09/04/2018 Board action based on felony conviction of MD in State of North Carolina v. John Woodruff Kessel, 14 CRS 56164, for Diversion of a Controlled Substance by a Registrant. The Board served MD with a Notice of Revocation in June 2018 and having received no request for a hearing, the Board has revoked the MD’s license.

Revocation of NC medical license

SUSPENSIONS BARNETT, Kari Chappell, AA (100000265) Fayetteville, NC

08/01/2018 In January 2018 during a workshift at a surgical center, AA diverted small amounts of fentanyl ordered for administration to patients. After accumulating approximately 250 micrograms of fentanyl, AA self-administered the controlled substance. Later in the shift, AA ingested propofol and then treated three patients after taking the drugs. AA's diversion was uncovered when staff at

Indefinite Suspension of NC Anesthesiologist Assistant License

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the surgical center found empty syringes in a restroom and contacted local law enforcement. During the investigation, AA was discovered to have fresh track marks on her arm. She admitted to the diversion and was arrested the next day. After her arrest, AA’s carry bag was searched, and the search revealed vials of fentanyl and propofol. AA was charged with felony embezzlement of a controlled substances. The criminal charge is still pending.

HAGAN, (Jr.), Paul, MD (000035907) Holly Springs, NC

10/10/2018 MD admitted that he engaged in an inappropriate personal and sexual relationship with his patient from March 2015 to August 2015.

Indefinite Suspension, effective May 7, 2018.

HALL, Brent Dwayne, MD (000034026) Boone, NC

10/25/2018 MD has a history of alcohol use disorder. MD attended inpatient treatment for this beginning in February 2018 and the Board entered into an Interim Non-Practice Agreement where MD agreed not to practice medicine until given permission to do so by the Board President. MD successfully completed inpatient treatment in May 2018, signed a monitoring contract with NCPHP and MD’s Interim Non-Practice Agreement was dissolved by a Board

NC Medical license suspended for 90 days, immediately stayed with conditions

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Order. NCPHP has determined that MD is safe to practice medicine and is in compliance with his NCPHP contract.

HART, Darlington Ibifubara, MD (009800560) Charlotte, NC

10/18/2018 MD has a history of alleged sexual assault/boundary violations. MD failed to comply with an April 2014 Board order that required that he examine female patients only in the presence of a chaperone.

Indefinite Suspension, immediately stayed with conditions; MD shall not examine or otherwise treat any female patient nor supervise advance practice providers who examine or treat female patients.

SKEEN, James Thomas, MD (009801061) Clemmons, NC

10/18/2018 Quality of care. Upon review of patient records, NCMB had many concerns about MD’s inadequate medical record keeping and diagnostic and treatment skills.

Indefinite suspension, immediately stayed; MD’s license placed on probation with conditions.

TURNER, Lee Leatherwood, MD (201101454) Morganton, NC

10/26/2018 Board executed an Interim Non-Practice Agreement in May 2018 after learning the MD was charged in Burke County, NC, with several driving offenses stemming from a car accident that caused injury. MD was assessed by the North Carolina Physicians Health Program (NCPHP) and referred for inpatient treatment for multiple substance use disorders. NCPHP has opined that MD can safely return to the practice of medicine; MD has signed a five-year monitoring contract with NCPHP.

Interim non-practice agreement dissolved; NC Medical license suspended until 10/26/18. MD to comply with current NCPHP contract.

WHITE, Anne Litton, MD (000029552) Winston-Salem, NC

08/23/2018 MD has a history of multiple actions with the

Indefinite suspension of NC medical license,

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Board. In 2017, the Board received information concerning quality of care provided by MD and opened an investigation in which several of her former employees were interviewed about substandard clinical practices. The Board heard this matter June 20-21, 2018 and found that MD committed unprofessional conduct and departed from the standards of acceptable and prevailing medical practice.

immediately stayed; MD on probation with several numbered conditions outlined, three years of monitoring for conditions compliance, and MD must complete a ProBE course.

WILEY, Jerry William, MD (000021616) Raleigh, NC

10/22/2018 MD admitted to making inappropriate sexual comments to three of his patients and leaving inappropriate sexual voicemails and sending inappropriate sexual text messages to two of them.

Indefinite suspension of NC medical license; As a condition of any reinstatement application that MD may make, he agrees that he shall be evaluated by the Professional Renewal Center or Acumen Assessments and follow all recommendations.

PROBATION/CONDITIONS FLOM, Jonathan Andrew, MD (200400331)

10/10/2018 In August 2017 MD entered into a Consent Order with the Board in which his license to practice medicine was indefinitely suspended, due to his history of severe alcohol use disorder and involvement in an April 2017 motor vehicle accident that resulted in a DWI charge. Since May 2017, MD has received outpatient treatment

MD's license reinstated with conditions

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and monitoring for alcohol dependence and signed a five-year monitoring contract with NCPHP, which has deemed MD safe to return to the practice of medicine.

ZAHRA, Michael Sorkis, MD (201602482) Florissant, MO

08/08/2018 In June 2016, MD applied to the NC Board for a medical license and failed to disclose previous actions from the Illinois Medical Board from 2015 and 2016. Additionally, in June 2017, MD was charged with Driving While Impaired and later diagnosed with alcohol use disorder. He has entered into a 5-year monitoring contract with the Missouri Physicians Health Program and with the North Carolina Physicians Health Program.

Consent Order; MD to comply with his NCPHP contract and fined $500.00.

REPRIMANDS BOWLES, III, Robert Bradford, MD (009500517) Fayetteville, NC

09/05/2018 Board is concerned about unprofessional conduct by MD. MD treated a patient and was her primary physician from 2010 to April 2017. After discharging her as a patient, he began an intimate relationship with her on or about June 2017 through December 2017. MD prescribed controlled substances for her on two occasions. Additionally, in December 2017, MD was

Reprimand

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involved in a domestic dispute with his former patient. MD was assessed by the North Carolina Physicians Health Program (NCPHP) which resulted in MD receiving inpatient treatment for alcohol use disorder from April 2018 to June 2018. In June 2018, MD signed a contract with NCPHP and he is currently in full compliance.

FOXWORTH, Scott Steven, PA (001005045) Hope Mills, NC

08/16/2018 In February 2018, the Board received notification from the Fayetteville Police Department (FDP) that the PA prescribed Norco (Hydrocodone-Acetaminophen), a Schedule II controlled substance, to a person with whom he has a significant personal and emotional relationship and did not prepare any documentation or medical charting for the prescription. FPD advised the Board that PA and this person had tried to obtain the prescription at two pharmacies, both of which refused to fill the prescription upon verification that the person for whom the prescription was written for was not a patient of the PA's practice. Additionally, while attempting to fill the prescription, PA called

Reprimand; PA shall complete a CME on controlled substance prescribing practices.

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his practice and instructed staff to advise the pharmacy that Person A was a patient at the practice if the pharmacy called.

ISMAIL, Samina, MD (200401518) Raleigh, NC

11/08/2018 MD has been accused of shoplifting on multiple occasions. These accusations led MD to be ordered by the Board to undergo a psychiatric assessment and comply with all recommendations.

Reprimand; MD shall receive ongoing psychotherapy consistent with the recommendations in psychiatric assessment. The psychotherapist shall provide monthly reports to the Board.

KIRTLEY, (Jr.), Thomas Lloyd, MD (000028768) Morehead City, NC

10/26/2018 MD prescribed Ambien (Zolpidem Tartrate), a Schedule IV Controlled Substance, to one of his patients. The patient returned the prescription to MD because the patient found it to be ineffective, and MD took personal possession of the Ambien.

Reprimand

LAICER, Cleopatra, DO (201001222) Winston-Salem, NC

10/01/2018 Action taken by another medical board; The NC Medical Board is concerned that DO entered into a Consent Agreement and Order with the New York State Board for Professional Medical Conduct in which DO received a Censure and Reprimand and was placed on probation for a period of five years retroactive to March 13, 2017, with

Reprimand; DO’s NC license is placed on probation for 5 years.

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conditions. The New York Consent Order was based on DO’s conviction in June 2017 of Driving While Intoxicated in New York.

MEHFOUD, George Joseph, MD (201601230) Richmond, VA

08/14/2018 Action taken by another state medical board; NCMB is concerned that in April 2018, MD entered into a Consent Order with the Virginia Board of Medicine which found that MD continue to diagnose a patient with having syncopal episodes even though other physicians had diagnosed the patient with having seizures. MD cleared his patient to drive in contravention of the medical advice that the patient had received from other physicians and soon after being cleared to drive by MD, patient had a seizure and crashed his car into a house.

Reprimand

NARASIMHAN, Lakshmi M.R., MD (009500674) Jacksonville, NC

10/22/2018 MD suffers from alcohol use disorder. In January 2018, MD was intoxicated with a blood alcohol content of .42. While under the influence of alcohol, MD accessed medical records of at least one patient and read an electro-cardiogram.

Reprimand

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MD’s hospital privileges were subsequently suspended, and MD signed a Medical Non-Practice Agreement (NPA) with the Board. MD participated in programs and meetings towards supporting his recovery, attended inpatient treatment in April 2018, and signed a 5-year monitoring contract with NCPHP. In April 2018, the Board approved MD’s request to be released from his NPA, allowing him to return to the practice of medicine.

OKOLI, Alphonsus Eziagwu, MD (009600661) Silver Spring, MD

11/19/2018 Action taken by another state medical board action; In June 2018, the Maryland State Board of Physicians issued MD a reprimand and placed him on a minimum two-year probation with conditions. The Maryland Consent Order was based on MD’s failure to meet the standards of quality medical care, including inappropriate prescribing of opioids and failure to keep adequate medical records.

Reprimand; MD placed on probation for a minimum of two years with conditions.

PIZARRO, (Sr.), Glenn, MD (009601772) Amsterdam, NY

11/20/2018 Action taken by another state medical board; The

Reprimand

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NC Board is concerned that MD entered into a Consent Agreement and Order with New York State Board for Professional Medical Conduct (New York Board) in which MD received a Censure, Reprimand, and $2,500 fine. The New York Consent Order was based on MD’s documenting a false progress note and addendum to his patient's chart in October 2016. The New York Board found that the documented evaluations of the patient were false, that the MD knew they were false, and that he intended to mislead through the false statements. Further, the New York Board found that MD failed to maintain an accurate medical record of his care and treatment of the patient.

UYESUGI, Walter Yutaka, DO (200801776)

08/31/2018 In 2010, a sixty-eight-year-old, anticoagulated woman presented to the ER at Indiana Regional Medical Center after suffering a fall at her home and a head CT was obtained. The DO, an

Reprimand; DO fined $500.00.

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out-of-state teleradiologist, read the CT scan as showing “small vessel ischemic changes” with “no evidence of acute infarct, hemorrhage or midline shift” identified. After patient's conditions worsened, a follow-up CT was performed 4.5 hours later and was interpreted by a different radiologist. The newer CT scan showed a large subdural hematoma with mass effect and midline shift. The patient was transferred to the University of Pittsburgh Medical Center and later died. The Board obtained the patient's medical records and had an independent reviewing expert in the specialty area of radiology review the records. The reviewing expert opined that the CT scan was abnormal but that DO read the scan as having “no acute findings.” The reviewing expert opined that the standard of care in North Carolina would have called for DO to identify the abnormality and provide a differential diagnosis.

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DENIALS OF LICENSE/APPROVAL LEGENDRE, Emile Willard, PA Durham, NC

11/27/2018 PA was denied a license to practice in NC due to an academic misconduct charge of unethical behavior and willful violations of Louisiana State University’s attendance policy while he attended school. Additionally, PA made false statements and representations to the Board during his application process.

Denial of Licensure

SURRENDERS NONE PUBLIC LETTERS OF CONCERN AZZATO, John Anthony, MD (000020698) Southport, NC

11/30/2018 Board is concerned that MD aided and abetted the unlicensed corporate practice of medicine, engaged in fee-splitting, and violated the Corporate Practice of Medicine doctrine. MD acted as “owner” of five clinics that were controlled by two non-physicians. This became evident after the de facto lay owners defaulted on a fraudulently obtained three-million-dollar loan, causing the clinics to be placed in receivership and then closed. The abrupt closure without notice to patients, led to disruption of continuity of care for patients as well as patients being unable to obtain their records.

Public Letter of Concern

COOPER, Joseph Litton, MD (009700907) Kenansville, NC

10/05/2018 In July 2016, the Board received information


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regarding concerns with MD's quality of care, communication and medical recordkeeping. The Board submitted MD's medical records of ten patients for review by two external expert reviewers. In four cases, both experts found that aspects of MD's care failed to conform to the standards of acceptable medical practice in North Carolina and expressed several concerns about MD's medical records and treatment. Specifically, the reviewing experts opined that the records should contain more detail and expressed concern about the legibility of the medical record documentation.

CRACKER, Andrew John-Edward, MD (000035305) Raleigh, NC

10/08/2018 In July 2015, a patient presented to MD for an elective termination of her pregnancy. A pre-procedure sonogram documented a 19-week twin gestation. MD failed to review the sonogram report prior to performing the procedure. Although the termination was performed under ultrasound guidance, MD failed to detect a second fetus. The patient was observed for one hour after the procedure and discharged home, where the patient passed the second fetus. The Board is concerned that MD


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failed to recognize the patient's 19-week twin gestation, failed to properly treat the patient, and failed to adequately maintain the patient's medical record.

ENSLOW, (Jr), William Lewis, DO (201001999) Morganton, NC

11/29/2018 Quality of care; The Board is concerned with DO’s treatment of a patient who presented to a hospital emergency department (ED) with complaints of fever and headache. After a prolonged workup, several tests and multiple evaluations, the patient was discharged with a diagnosis of Viral Syndrome/Influenza. DO was later notified that the patient’s blood cultures were positive for G+ cocci (Strep pneumonia) and had patient return to the ED immediately. Upon return to the ED, the patient was in respiratory distress and hypotensive, was in rapid decline and ultimately died. The Board’s reviewer thought DO should have considered administering IV antibiotics in the ED until a bacterial infection was being ruled out.


FLECHAS, Jorge David, MD (000024245) Hendersonville, NC

10/10/2018 Board is concerned that MD’s diagnosis, treatment, records, and overall care of his patient fell below the standard of care in North Carolina.

Public Letter of Concern; MD to complete a CME course on medical record keeping.

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FRANK, Harrison Gabriel, MD (201101636) Wilmington, NC

11/14/2018 MD aided and abetted the unlicensed corporate practice of medicine, engaged in fee-splitting, and violated the Corporate Practice of Medicine doctrine by holding the position of “owner” for several medical practices that were controlled by two non-physicians. This was discovered after the de facto owners defaulted on a fraudulently obtained three-million-dollar loan, causing the practices to be closed. This abrupt closure of the practices led to disruption in continuity of care and difficulties for patients in obtaining copies of medical records.


MARING, Timothy Matthew, PA-C (001005962) Watertown, NY

08/14/2018 Quality of care issue; PA treated a two-year-old male with a history of asthma at an urgent care center in December 2017. The patient’s foster parents were concerned that he may be in respiratory distress as he had been unresponsive to a home nebulizer treatment and antibiotics, which were previously prescribed by a primary care provider. According to the foster mother, his oxygen saturation was 86%, which level PA attributed to a faulty oximeter device. Following a cursory history and physical examination PA


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prescribed prednisolone and instructed Patient A’s foster mother to follow-up with his primary care provider in seven to ten days. Within approximately three hours of discharge, the patient was taken to an emergency department, where he was found to be hypoxic with oxygen saturation of 83% and in respiratory distress. He was transferred by EMS to a larger hospital, where he was diagnosed with pneumonia and hospitalized for two days.

O'ROURKE, (III), Peter John, MD (009601686) Greenville, NC

09/26/2018 In May 2012, a patient underwent a diagnostic cerebral angiogram with coil embolization surgery. During surgery, the patient experienced an episode of increased carbon dioxide in her bloodstream, initially believed to be related to equipment performance. MD initiated treatment recommendations including absorber and monitor changes and left to attend to other patient responsibilities. MD was not notified that patient's end tidal CO2 levels remained elevated for a period of time following these actions. Patient A remained


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intubated and unstable postoperatively while in intensive care, required a blood transfusion and a vasoactive infusion and was unresponsive. A cerebral perfusion scan showed absent intracerebral arterial pressure and the patient was ultimately declared brain dead.

The Board is concerned that MDs communication between the neurosurgeon impacted the patient’s care and that MD failed to provide adequate anesthesia support and treatment of prolonged, elevated carbon dioxide levels to ensure the best outcome for the patient.

PARK, Aaron, MD (201702466) Mebane, NC

10/23/2018 The Board is concerned that, on more than one occasion, MD prescribed controlled substances to a person with whom MD had a significant personal and emotional relationship. Additionally, MD did not prepare any documentation or medical charting for any of the prescriptions and did not contact the individuals’ treating physician to report the prescriptions MD authorized.


PATEL, Parth Dipam, MD (201702270) Chapel Hill, NC

11/28/2018 MD accessed the medical record of an individual who was not


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his patient, without that individual’s permission. In addition, the Board is concerned that MD misled a hospital privacy officer who inquired about the incident.

PEREZ-RIVERA, Efrain, MD (009401300) Smithfield, NC

11/20/2018 Action taken by another state medical board; The NC Board is concerned that MD entered into a consent order with the West Virginia Board of Medicine (WV Board) which found that MD inaccurately certified compliance with the WV Board CME requirements for the July 2017 through June 2019 renewal cycle. The complaint was resolved via a June 2018 consent agreement, in which MD was fined $500.00 and was required to read the WV Board’s Legislative Rule, Continuing Education for Physicians and Podiatrists.


RAY, Julia, MD (201100262) Fayetteville, NC

10/02/2018 The Board is concerned about the treatment of a patient that presented for a scheduled outpatient elective shoulder surgery under general anesthesia. Despite multiple attempts to intubate the patient the MD was unable to and the surgery was cancelled. The patient was observed for a brief period and discharged. The next day the patient developed difficulty breathing, was


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hospitalized for upper airway compromise, and underwent an emergency tracheotomy. Upon a record review by an outside medical expert, the reviewing expert opined that there were deficiencies in MDs care of the patient, including criticisms of the pre-operative evaluation, pre- and post-operative treatment, inadequate documentation, and limited equipment availability.

SAAD, Maged Hanna, MD (000020192)

10/26/2018 The Board is concerned that in 2010, MD sold his medical practice to a non-licensee and, after the sale, MD engaged in unethical fee-splitting by continuing to practice medicine at the clinic on behalf of the lay owner. MD retired in 2015 and a new physician was brought into the practice. In 2017, the practice abruptly closed without notice to patients which led to led to disruption of continuity of care for several patients as well as patients being unable to obtain their records. Although MD was not involved with the practice in 2017 when it closed, the initial sale of the practice in 2010 to a non-licensee set in motion the course of events that ultimately led to the inappropriate


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abrupt closure of the practice by a lay person unbound to medical ethics.

TAMBAKIS-ODOM, Constance Roseann, MD (200201414) Wilmington, NC

11/06/2018 The Board is concerned that MD wrote hormone prescriptions for an immediate family member from November 2014 to March 2016 and controlled substances in 2013, 2015, and 2016. MD also wrote a controlled substance prescription for a friend in March 2013. None of the inappropriate prescriptions were adequately documented in a medical record. These actions are prohibited by Administrative Rule 21 NCAC 32B .1001.

Public Letter of Concern; MD to complete a ProBE course.

WAGNER, Thomas Herbert, MD (201600802) Colorado Springs, CO

08/22/2018 The NC Board is concerned that in December 2016, the Florida Board entered a Final Order adopting the Settlement Agreement that imposed a Letter of Concern, a $2,000.00 fine, required MD to complete five hours of continuing medical education in risk management, and within six months of the Final Order, present a lecture/seminar on wrong site surgery to the medical staff of an approved medical facility. The Settlement Agreement and Final Order resolved an Administrative Complaint, filed by the


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Florida Board, that alleged MD mistakenly performed a wrong-site surgery in July 2015.

YAEGER, Edwin Paul, DO (009501157) Wilson, NC

11/27/2018 Quality of care. Upon review of two patient records, NCMB found that DO did not adequately evaluate, recognize or act on the patients’ complications or complaints which resulted in the death of one patient and misdiagnosis and protracted care in the other.

Public Letter of Concern, DO to complete a comprehensive multiday emergency medicine continuing medical education review course.

ZABENKO, Robert Tracy, DO (009800166) Fort Gordon, GA

10/16/2018 The Board is concerned about the quality of care that DO provided to one of his patients concerning the delivery of her baby, which may have failed to conform to acceptable and prevailing standards of medical practice.


MISCELLANEOUS ACTIONS KIM, Jong Whan, MD (200101455) Tabor City, NC

09/05/2018 MD was arrested by the Columbus County Sheriff’s Office and criminally charged on June 29, 2018, with fifteen felony crimes related to inappropriate use and distribution of controlled substances. The Board is currently investigating this matter.

Interim Non-Practice Agreement; MD agrees that he will not practice medicine until he is given permission to do so by the Board President.

O'NEIL, (Jr.), James Timothy, MD (201300038) Raleigh, NC

08/17/2018 In June of 2017, the Board received a letter from the hospital where MD worked regarding MD’s resignation following discovery of an

NC medical license inactivated

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inappropriate sexual and/or romantic relationship with two residents that the MD supervised. To address the issues underlying his conduct and prevent its reoccurrence, MD entered into a contract with the North Carolina Physicians Health Program (NCPHP) who reports that MD is fully compliant with his NCPHP contract and has made excellent therapeutic progress. In April 2018, MD requested that his North Carolina medical license become inactive since he is not practicing medicine in North Carolina.

SAPPINGTON, John Shannon, MD (009400628) Casper, WY

10/16/2018 Action taken by another state medical board; NCMB is concerned that MD's Rhode Island medical license had been summarily suspended as a result of a complaint being made that MD violated his April 2018 Rhode Island Amended Consent Order by prescribing controlled substances without first checking the Rhode Island Prescription Drug Monitoring Program.

Interim Non-Practice Agreement, MD agrees that he will not practice medicine until he is given permission to do so by the Board President.

CONSENT ORDERS AMENDED NONE TEMPORARY/DATED LICENSES: ISSUED, EXTENDED, EXPIRED, OR

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REPLACED BY FULL LICENSES VIJAY, Adarsh, MD (201802160) Chapel Hill, NC

08/10/2018 The Board issued a Special Purpose License to MD who seeks to be a clinical fellow at the University of North Carolina, Division of Abdominal Transplantation in the Department of Surgery beginning August 13, 2018 and ending August 5, 2019. MD shall not practice medicine or surgery with his North Carolina Special Purpose License outside the limitations set forth in this Special Purpose License Agreement. These limitations include MD’s participation as a clinical fellow at the University of North Carolina, Division of Abdominal Transplantation in the Department of Surgery.

Special Purpose License Agreement, Temporary/Dated Licenses Issued

COURT APPEALS/STAYS NONE DISMISSALS NONE

Documents

Name/license #/location Date of action Cause of action