Healthcare Provider Details

I. General information

NPI: 1700449295
Provider Name (Legal Business Name): JERRY PATRICK SKUTHAN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2019
Last Update Date: 10/02/2025
Certification Date: 10/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4414 LAKE BOONE TRL STE 402
RALEIGH NC
27607-7520
US

IV. Provider business mailing address

4414 LAKE BOONE TRL STE 402
RALEIGH NC
27607-7520
US

V. Phone/Fax

Practice location:
  • Phone: 919-567-6133
  • Fax: 919-567-6134
Mailing address:
  • Phone: 919-567-6133
  • Fax: 919-567-6134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2025-02910
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: