Provider Demographics
NPI:1245343011
Name:NOLLER, JERROL JAY (MD)
Entity type:Individual
Prefix:DR
First Name:JERROL
Middle Name:JAY
Last Name:NOLLER
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:1416 OAKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ANOKA
Mailing Address - State:MN
Mailing Address - Zip Code:55303-2747
Mailing Address - Country:US
Mailing Address - Phone:763-427-6897
Mailing Address - Fax:763-433-8308
Practice Address - Street 1:3863 COON RAPIDS BLVD NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-2518
Practice Address - Country:US
Practice Address - Phone:763-433-8300
Practice Address - Fax:763-433-8308
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
MN23068207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA95037Medicare UPIN