Basic Information
| Provider Information | |||||||||
| NPI: | 1205258431 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOLLER | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | STEVEN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 79 HOLDER ROAD | ||||||||
| Address2: | |||||||||
| City: | LUMPKIN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2298381241 | ||||||||
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| Practice Location | |||||||||
| Address1: | 76 HOLDER ROAD | ||||||||
| Address2: | |||||||||
| City: | LUMPKIN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2298381241 | ||||||||
| FaxNumber: | 2298381242 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2014 | ||||||||
| LastUpdateDate: | 06/30/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SF0001X | RN218792 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Family Health |
No ID Information.