Healthcare Provider Details

I. General information

NPI: 1073491635
Provider Name (Legal Business Name): SKYLAR GODARD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SKYLAR GODARD PA

II. Dates (important events)

Enumeration Date: 08/22/2025
Last Update Date: 10/29/2025
Certification Date: 10/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11125 DUNN RD STE 301
SAINT LOUIS MO
63136-6132
US

IV. Provider business mailing address

PO BOX 959354
SAINT LOUIS MO
63195-9354
US

V. Phone/Fax

Practice location:
  • Phone: 314-953-8250
  • Fax:
Mailing address:
  • Phone: 314-953-8250
  • Fax: 314-953-8255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2025033996
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: