MEDICARE: SKYLAR GODARD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	2025033996	MO

General Provider Information

NPI Number	:	1073491635
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SKYLAR GODARD

Provider Business Mailing Address
First Line	:	PO BOX 959354
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63195-9354
Country	:	US
Telephone Number	:	314-953-8250
Fax Number	:	314-953-8255

Provider Business Practice Location Address
First Line	:	11125 DUNN RD STE 301
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63136-6132
Country	:	US
Telephone Number	:	314-953-8250
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/22/2025
Last Update Date	:	12/17/2025

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Directions to “ SKYLAR GODARD ” Practice Location

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