Provider Demographics
NPI:1922574433
Name:DEWITT-COON, SKYLER RAE (PA)
Entity Type:Individual
Prefix:
First Name:SKYLER
Middle Name:RAE
Last Name:DEWITT-COON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 KRESGE WAY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4660
Mailing Address - Country:US
Mailing Address - Phone:502-893-7710
Mailing Address - Fax:
Practice Address - Street 1:3900 KRESGE WAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4660
Practice Address - Country:US
Practice Address - Phone:502-893-7710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-23
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008792363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601008792OtherMICHIGAN PHYSICIAN ASSISTANT LICENSE