Provider Demographics
NPI:1043625809
Name:KOELLER, JENNIFER (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:KOELLER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3130
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34478-3130
Mailing Address - Country:US
Mailing Address - Phone:352-867-3262
Mailing Address - Fax:352-622-5771
Practice Address - Street 1:700 DOCTORS CT
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-7314
Practice Address - Country:US
Practice Address - Phone:352-787-9838
Practice Address - Fax:352-787-8705
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-30
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108194363AS0400X
NJ25MP00337400363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9108194OtherMEDICAL LICENSE
FLIV450XMedicare PIN
FLIV450YMedicare PIN
FLPA9108194OtherMEDICAL LICENSE