Provider Demographics
NPI:1497060727
Name:KOLLER, NATHAN W (PA)
Entity Type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:W
Last Name:KOLLER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 UPPER CHESAPEAKE DR
Mailing Address - Street 2:
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21014-4324
Mailing Address - Country:US
Mailing Address - Phone:443-643-1500
Mailing Address - Fax:443-643-1505
Practice Address - Street 1:500 UPPER CHESAPEAKE DR
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014-4324
Practice Address - Country:US
Practice Address - Phone:443-643-1500
Practice Address - Fax:443-643-1505
Is Sole Proprietor?:No
Enumeration Date:2010-08-11
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0004217363A00000X
PAMA064644363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant