Lipid transport is an essential process with manifest importance to human health and disease. Phospholipid flippases (P4-ATPases) transport lipids across the membrane bilayer and are involved in signal transduction, cell division, and vesicular transport. Mutations in flippase genes cause or contribute to a host of diseases, such as cholestasis, neurological deficits, immunological dysfunction, and metabolic disorders. Genomewide association studies have shown that ATP10A and ATP10D variants are associated with an increased risk of diabetes, obesity, myocardial infarction, and atherosclerosis. Moreover, ATP10D SNPs are associated with elevated levels of glucosylceramide (GlcCer) in plasma from diverse European populations. Although sphingolipids strongly contribute to metabolic disease, little is known about how GlcCer is transported across cell membranes. Here, we identify a conserved clade of P4-ATPases from Saccharomyces cerevisiae (Dnf1, Dnf2), Schizosaccharomyces pombe (Dnf2), and Homo sapiens (ATP10A, ATP10D) that transport GlcCer bearing an sn2 acyl-linked fluorescent tag. Further, we establish structural determinants necessary for recognition of this sphingolipid substrate. Using enzyme chimeras and site-directed mutagenesis, we observed that residues in transmembrane (TM) segments 1, 4, and 6 contribute to GlcCer selection, with a conserved glutamine in the center of TM4 playing an essential role. Our molecular observations help refine models for substrate translocation by P4-ATPases, clarify the relationship between these flippases and human disease, and have fundamental implications for membrane organization and sphingolipid homeostasis. Phospholipid flippases in the P4-ATPase family establish and repair the phospholipid asymmetry of cellular membranes and facilitate import of phospholipid from extracellular sources (1). These enzymes are integral membrane proteins that harness energy from ATP catalysis to translocate lipids from the exofacial leaflet to the cytofacial leaflet of cellular membranes. There are 14 distinct P4-ATPases in humans with important differences in tissue-specific expression, subcellular localization, and substrate specificity (2). These differences in P4-ATPase localization and enzymology are important for coordinating physiological processes, and their impairment results in diverse pathologies (3). For example, the P4-ATPase ATP8B1 transports phosphatidylcholine at the apical membrane of canalicular hepatocytes (4), and mutations in the ATP8B1 gene lead to membrane damage and hepatic cholestasis (3, 5). Conversely, ATP8A2 translocates phosphatidylserine within the central nervous system, and mutations in ATP8A2 cause cerebellar ataxia mental retardation and disequilibrium syndrome in humans and motor neuron degeneration in mice (6-8). Thus, defining the substrate specificity of the P4-ATPases is crucial to understanding their role in disease. Genome-wide association (GWA) 3 studies have found that SNPs in the human P4-ATPase genes ATP10A and ATP10D are strongly linked with meta...