Provider Demographics
NPI:1205895075
Name:KOLLER, PATRICK THOMAS
Entity type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:THOMAS
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 1:45 WEST 10TH STREET
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55102
Mailing Address - Country:US
Mailing Address - Phone:651-232-3163
Mailing Address - Fax:
Practice Address - Street 1:1700 UNIVERSITY AVE W FL 6
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-3727
Practice Address - Country:US
Practice Address - Phone:651-232-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN35944207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32434700Medicaid
MN359872100Medicaid
MNB47033Medicare UPIN
WI32434700Medicaid