Healthcare Provider Details

I. General information

NPI: 1215790639
Provider Name (Legal Business Name): JEFFREY ALLAN KOLLER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2024
Last Update Date: 01/31/2024
Certification Date: 01/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 SE CHURCH ST
SUBLIMITY OR
97385-9424
US

IV. Provider business mailing address

4847 VERDA LN NE APT 302
KEIZER OR
97303
US

V. Phone/Fax

Practice location:
  • Phone: 503-769-2259
  • Fax:
Mailing address:
  • Phone: 605-760-0590
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA218511
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: