Provider Demographics
NPI:1487840021
Name:SKAGGS, GARY H
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:H
Last Name:SKAGGS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5520 S SANTA AURELIA AVE
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85650-9373
Mailing Address - Country:US
Mailing Address - Phone:520-803-7130
Mailing Address - Fax:
Practice Address - Street 1:5520 S SANTA AURELIA AVE
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85650-9373
Practice Address - Country:US
Practice Address - Phone:520-803-7130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-18
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5737385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ660567Medicaid