A. A physician assistant licensed in this state, prior to initiating practice, shall submit, on forms approved by the board, notification of such intent to practice. Such notification shall include:
(1) The name, business address, and telephone number of the supervising physician.
(2) The name, business address, and telephone number of the physician assistant.
B. A physician assistant shall notify the board of any changes in or additions to his supervising physicians within thirty days of the date of such change or addition.