Provider Demographics
NPI:1972012482
Name:DRISCOLL, MALLORY (PA-C)
Entity Type:Individual
Prefix:MS
First Name:MALLORY
Middle Name:
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 1:17025 SNOWMOBILE LN
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-7044
Mailing Address - Country:US
Mailing Address - Phone:907-696-7466
Mailing Address - Fax:
Practice Address - Street 1:17025 SNOWMOBILE LN
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-7044
Practice Address - Country:US
Practice Address - Phone:907-696-7466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-27
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN13162363A00000X
UT11674343-1206363A00000X
NDPAC0801363A00000X
AK153300363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1478531Medicaid
MN1972012482Medicaid
AK1699289Medicaid