Provider Demographics
NPI:1821115544
Name:DRISCOLL, MICHAEL R (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:DRISCOLL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 APPLETON ST
Mailing Address - Street 2:APT M2
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-5210
Mailing Address - Country:US
Mailing Address - Phone:404-520-4385
Mailing Address - Fax:
Practice Address - Street 1:114 WHITWELL ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-1870
Practice Address - Country:US
Practice Address - Phone:617-773-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004753363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant