Provider Demographics
NPI:1417402793
Name:DRISCOLL, MATTHEW (PA-C, ATC, CSCS)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:DRISCOLL
Suffix:
Gender:M
Credentials:PA-C, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 BUCKNAM RD STE 1D
Mailing Address - Street 2:
Mailing Address - City:FALMOUTH
Mailing Address - State:ME
Mailing Address - Zip Code:04105-1208
Mailing Address - Country:US
Mailing Address - Phone:207-781-1551
Mailing Address - Fax:
Practice Address - Street 1:5 BUCKNAM RD STE 1D
Practice Address - Street 2:
Practice Address - City:FALMOUTH
Practice Address - State:ME
Practice Address - Zip Code:04105-1208
Practice Address - Country:US
Practice Address - Phone:207-781-1551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-17
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL46722255A2300X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer