Regulation of physician assistants (PAs) and nurse practitioners (NPs) varies both between professions and within them. State-by-state differences in approaching regulation of NPs and PAs raises questions about which models are the most effective. It also helps provide the framework for understanding the advocacy initiatives of both professions, including goals for modernizing the regulation of PAs.

There is much more uniformity within the regulation of NPs compared with PAs. In most states, the NP practice is overseen by the state’s nursing board or its equivalent.2   In North Carolina, for example, NPs are overseen by both the North Carolina Nursing Board as well as the state Medical Board. This dual regulation is enforced by the NP Joint Subcommittee, which includes members of both the Board of Nursing and Medical Board. The subcommittee is responsible for developing scope of practice (SOP) rules and other requirements for NPs in North Carolina.3

Not surprisingly, this is a hot topic for NPs in North Carolina, many of whom support moving oversight solely to the Nursing Board. The North Carolina Nurses Association has made it a key priority for the last several years to create and support legislation that would move the regulatory oversight of NPs solely to the NC Nursing Commission, though this legislation has yet to pass.4

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Nationally, NPs are striving for full practice authority (FPA). The American Association of Nurse Practitioners (AANP) defines FPA as “the authorization of NPs to evaluate patients, diagnose patients, order and interpret diagnostic tests, and initiate and manage treatments — including prescribe medications — under the exclusive licensure authority of the state board of nursing.”5 Approximately half of US states have some version of FPA.5

Like NPs, PA regulation happens at the state level, although certification of PAs is a national matter. When PA students graduate, almost all seek certification through the independent National Commission on Certification of Physician Assistants (NCCPA), and then complete a recertification test every 10 years to assess their “Core Medical Knowledge.”6 While states individually license PAs to practice, they leave certification maintenance up to the PAs and the NCCPA. 

This type of testing, frequently referred to as “high-stakes” testing, is a hot topic within the profession. Many PAs, myself included, are specialists, and the testing primarily focuses on primary care content based on what that NCCPA describes as their testing “blueprint.”7 For PAs like myself, who have never worked in primary care, it can be a burdensome process to be tested on material that often has little relevance to the clinical practice of specialist PAs.

State boards and commissions that regulate PAs differ greatly from state to state. Some states, such as Washington (where I practice), have “hybrid” boards, where PAs and physicians (MDs) serve on the same governing bodies. I am 1 of 2 PAs on the Washington Medical Commission; in our state, PA and MD commission members share oversight of both PAs and MDs. Some states, including Washington, have separate boards for osteopaths and osteopathic PAs, while others combine them.8

There are other models in place as well. The Texas Medical Board includes a separate PA Board, made of PAs, MDs, and public members.9 PAs continue to work with MDs and other stakeholders to modernize regulation of PAs related to SOP.10 This process continues to evolve, as PAs work with their state regulators to fully optimize SOP rules and regulations.

Individual states continue to update and modernize their regulations yearly, usually done at the state legislative level as a collaboration between PAs, MDs, and other state stakeholders. The American Academy of PAs (AAPA) is a national professional organization for PAs, and much of their work is supporting the optimization of practice rules for PAs around the nation in conjunction with state PA organizations.11

In the end, as with NPs, one size does not fit all regarding the regulation of PA practice, including the individual oversight of PA practice as well as managing broader rules regarding the general practice of PAs.

There has been marked progress in the last several years in enhancing collaboration between PA and NP organizations. The goal of such collaboration is identifying and removing outdated obstacles to the full practice of PAs and NPs to provide safe and evidence-based care to patients in conjunction with the variety of legislative, medical, and nursing stakeholders who work alongside PAs and NPs every day.


  1. How does NP practice authority vary by state? Nurse Practitioner Schools. Published October 26, 2020. Accessed November 11, 2020.
  2. Practice information by state. What you need to know about NP practice in your state. American Association of Nurse Practitioners (AANP) website. Accessed November 11, 2020.
  3. Nurse practitioner laws and rules. North Carolina Board of Nursing. Updated September 11, 2020. Accessed November 11, 2020.
  4. 2019-2020 NCNA legislative, regulatory, and political platform. North Carolina Nurses Association. Accessed November 11, 2020.
  5. Issue at a glance: full practice authority. American Association of Nurse Practitioners. Updated December 2019. Accessed November 11, 2020.,the%20state%20board%20of%20nursing.
  6. Content blueprint for Physician Assistant National Recertifying Examination (PANRE) and the pilot alternative to PANRE. National Commission on Certification of Physician Assistants. Accessed November 11, 2020.
  7. Content blueprint for PANCE. National Commission on Certification of Physician Assistants. Accessed November 11, 2020.
  8. Directory of state licensing boards for doctors of osteopathic medicine. Juris Med Legal Services. Accessed November 11, 2020.
  9. PA board overview. Texas Medical Board. Accessed November 11, 2020.
  10. Physician assistant scope of practice. American Medical Association. Accessed November 11, 2020.
  11. Learn more about AAPA. American Academy of Physician Assistants. Accessed November 11, 2020.