Provider Demographics
NPI:1205258431
Name:KOLLER, GARY STEVEN
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:STEVEN
Last Name:KOLLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 HOLDER ROAD
Mailing Address - Street 2:
Mailing Address - City:LUMPKIN
Mailing Address - State:GA
Mailing Address - Zip Code:31815
Mailing Address - Country:US
Mailing Address - Phone:229-838-1241
Mailing Address - Fax:
Practice Address - Street 1:76 HOLDER ROAD
Practice Address - Street 2:
Practice Address - City:LUMPKIN
Practice Address - State:GA
Practice Address - Zip Code:31815
Practice Address - Country:US
Practice Address - Phone:229-838-1241
Practice Address - Fax:229-838-1242
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-07
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN218792364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health