Provider Demographics
NPI:1417574450
Name:JAEN, CARLOS HUMBERTO SR (PA)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:HUMBERTO
Last Name:JAEN
Suffix:SR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1685 SW 17TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33145-2809
Mailing Address - Country:US
Mailing Address - Phone:305-742-9121
Mailing Address - Fax:
Practice Address - Street 1:2000 SW 27TH AVE # 301
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33145-2546
Practice Address - Country:US
Practice Address - Phone:305-461-2010
Practice Address - Fax:305-648-0140
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-25
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9112833363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical