Provider Demographics
NPI:1184264921
Name:DRISCOLL, LOGAN DAVID
Entity type:Individual
Prefix:
First Name:LOGAN
Middle Name:DAVID
Last Name:DRISCOLL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 NE CYPRESS CIR
Mailing Address - Street 2:
Mailing Address - City:GRIMES
Mailing Address - State:IA
Mailing Address - Zip Code:50111-1241
Mailing Address - Country:US
Mailing Address - Phone:515-991-6227
Mailing Address - Fax:
Practice Address - Street 1:12499 UNIVERSITY AVE STE 210
Practice Address - Street 2:
Practice Address - City:CLIVE
Practice Address - State:IA
Practice Address - Zip Code:50325-8288
Practice Address - Country:US
Practice Address - Phone:515-440-2676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-09
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant