Healthcare Provider Details

I. General information

NPI: 1417878075
Provider Name (Legal Business Name): SKYLAR ANN WICKMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2026
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3030 N CENTRAL AVE STE 803
PHOENIX AZ
85012-3054
US

IV. Provider business mailing address

3030 N CENTRAL AVE STE 803
PHOENIX AZ
85012-3054
US

V. Phone/Fax

Practice location:
  • Phone: 602-541-1575
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: