MEDICARE: MARY JORDAN DRISCOLL DNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	79647	ID

General Provider Information

NPI Number	:	1922966951
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY JORDAN DRISCOLL DNP

Provider Business Mailing Address
First Line	:	801 N STILSON RD STE 100
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83703-5142
Country	:	US
Telephone Number	:	208-332-4540
Fax Number	:	208-286-0565

Provider Business Practice Location Address
First Line	:	801 N STILSON RD STE 100
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83703-5142
Country	:	US
Telephone Number	:	208-332-4540
Fax Number	:	208-286-0565

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/09/2026
Last Update Date	:	01/09/2026

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