Provider Demographics
NPI:1043036932
Name:RAITT, SKYLAR
Entity type:Individual
Prefix:
First Name:SKYLAR
Middle Name:
Last Name:RAITT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3806 ISLAND PARK DR
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48329-1906
Mailing Address - Country:US
Mailing Address - Phone:248-880-1801
Mailing Address - Fax:
Practice Address - Street 1:25775 W 10 MILE RD STE B
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48033-4856
Practice Address - Country:US
Practice Address - Phone:248-450-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-25
Last Update Date:2025-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601012903363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant