Provider Demographics
NPI:1457863045
Name:DRISCOLL, SHANNON MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:DRISCOLL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1765 N ELSTON AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-1501
Mailing Address - Country:US
Mailing Address - Phone:773-276-1100
Mailing Address - Fax:773-276-1102
Practice Address - Street 1:1765 N ELSTON AVE STE 110
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60642-1501
Practice Address - Country:US
Practice Address - Phone:773-276-1100
Practice Address - Fax:773-276-1102
Is Sole Proprietor?:No
Enumeration Date:2017-11-03
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.006424207N00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207N00000XAllopathic & Osteopathic PhysiciansDermatology