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 1:3100 INTERSTATE NORTH CIR SE STE 500
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-2296
Mailing Address - Country:US
Mailing Address - Phone:770-953-6929
Mailing Address - Fax:
Practice Address - Street 1:6300 HOSPITAL PKWY STE 400
Practice Address - Street 2:
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30097-1983
Practice Address - Country:US
Practice Address - Phone:678-205-4261
Practice Address - Fax:678-417-7187
Is Sole Proprietor?:No
Enumeration Date:2016-08-17
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
GA12732363A00000X
FLAL46722255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer