Provider Demographics
NPI:1497285811
Name:JAEN, CONSTANTIN NAUTNAY (MD)
Entity type:Individual
Prefix:
First Name:CONSTANTIN
Middle Name:NAUTNAY
Last Name:JAEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:CONSTANTIN
Other - Middle Name:NAUTNAY
Other - Last Name:ROBLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3175 LILLY RD UNIT 107
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-7602
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2301 N LAKE DR
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211-4508
Practice Address - Country:US
Practice Address - Phone:414-585-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-18
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI74896-20207L00000X
PAMT213549207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology