Name Change

Pursuant to Business and Professions Code section 2021, licensees are required to report in writing to the Board each name change within 30 days from the date the change occurred.

It is the Board’s policy that the name in which a physician assistant license is issued, match their legal name. The physician assistant license detail, available on the Board’s website reflects both previous and current names.

How to Report Name Change
Name changes may only be submitted to the Board by mail. Licensees are not able to change their name through their BreEZe account. Licensees are required to submit photocopies of the following documents with a Notification of Name Change form:

  1. A current government issued photographic identification (e.g., driver’s license, alien registration, passport, etc.) 
  2. One of the following legal documents as proof of  name change

    a. Certified Court Order
    b. Marriage Certificate 
    c. Dissolution of Marriage

Name Changes are completed within 5 business days upon receipt of all required documents. There is no fee for a name change unless a duplicate Pocket ID Card or Wall Certificate is requested. If a Wall Certificate reflecting new name is requested, a Duplicate License Request form must be submitted with appropriate fees.