Healthcare Provider Details

I. General information

NPI: 1457100810
Provider Name (Legal Business Name): KYRA SKINNER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2024
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 S NEW BALLAS RD STE 297A
SAINT LOUIS MO
63141-8200
US

IV. Provider business mailing address

621 S NEW BALLAS RD STE 297A
SAINT LOUIS MO
63141-8200
US

V. Phone/Fax

Practice location:
  • Phone: 314-251-6364
  • Fax: 314-251-7897
Mailing address:
  • Phone: 314-251-6364
  • Fax: 314-251-7897

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2024013596
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: