Healthcare Provider Details

I. General information

NPI: 1205895075
Provider Name (Legal Business Name): DR. PATRICK THOMAS KOLLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2006
Last Update Date: 04/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 UNIVERSITY AVE W FL 6
SAINT PAUL MN
55104-3727
US

IV. Provider business mailing address

45 WEST 10TH STREET 3RD FLOOR
SAINT PAUL MN
55102
US

V. Phone/Fax

Practice location:
  • Phone: 651-232-2273
  • Fax:
Mailing address:
  • Phone: 651-232-3163
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number35944
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number35944
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: