Basic Information
| Provider Information | |||||||||
| NPI: | 1871925057 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DRISCOLL | ||||||||
| FirstName: | DEWEY | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4107 | ||||||||
| Address2: | |||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 832054107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082338880 | ||||||||
| FaxNumber: | 2082321950 | ||||||||
| Practice Location | |||||||||
| Address1: | 333 NORTH 18TH | ||||||||
| Address2: | BLDG A | ||||||||
| City: | POCATELLO | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082338880 | ||||||||
| FaxNumber: | 2082321950 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2013 | ||||||||
| LastUpdateDate: | 01/15/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RNA872A | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.