Provider Demographics
NPI:1194192864
Name:JEUTTER, KATHRYN BAILEY (PA-C, ATC)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:BAILEY
Last Name:JEUTTER
Suffix:
Gender:F
Credentials:PA-C, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3001 EDWARDS MILL RD STE 200
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-5243
Mailing Address - Country:US
Mailing Address - Phone:919-781-5600
Mailing Address - Fax:911-986-3682
Practice Address - Street 1:3001 EDWARDS MILL RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-5243
Practice Address - Country:US
Practice Address - Phone:919-781-5600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-28
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
20000316612255A2300X, 2255A2300X
NC0010-13281363A00000X
SC390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program