Provider Demographics
NPI:1316268311
Name:SKAGGS, DAVID ROBERT
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:ROBERT
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 1:2460 OLD MOULTRIE RD STE 5
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-4198
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2460 OLD MOULTRIE RD STE 5
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-4198
Practice Address - Country:US
Practice Address - Phone:904-797-5740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-14
Last Update Date:2020-11-16
Deactivation Date:2017-11-16
Deactivation Code:
Reactivation Date:2020-10-28
Provider Licenses
StateLicense IDTaxonomies
FL9105459363AM0700X
FL9113656363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical