Iconic Wellness Surgical Services

Primary specialty

Surgical Physician AssistantTaxonomy code 363AS0400X

License

25MP00262900 Issued in NJ

Legal business name

ICONIC WELLNESS SURGICAL SERVICES

Practice address

139 Harristown Rd
Ste 205
Glen Rock, NJ 07452-3312

Phone

(201) 444-1645

Fax

(201) 444-1787

NPI assigned

Jan 11, 2016

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mr. Sadyk Fayzulayev, PA

Title

Managing Member

Phone

(201) 444-1645

Specialties & licenses 1

Addresses

Locations

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1452470400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1452470400000",
    "number": "1316303035",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "139 HARRISTOWN RD",
            "address_2": "STE 205",
            "city": "GLEN ROCK",
            "state": "NJ",
            "postal_code": "074523312",
            "telephone_number": "201-444-1645",
            "fax_number": "201-444-1787"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "139 HARRISTOWN RD",
            "address_2": "STE 205",
            "city": "GLEN ROCK",
            "state": "NJ",
            "postal_code": "074523312",
            "telephone_number": "201-444-1645",
            "fax_number": "201-444-1787"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ICONIC WELLNESS SURGICAL SERVICES",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-01-11",
        "last_updated": "2016-01-11",
        "status": "A",
        "authorized_official_last_name": "FAYZULAYEV",
        "authorized_official_first_name": "SADYK",
        "authorized_official_title_or_position": "MANAGING MEMBER",
        "authorized_official_telephone_number": "201-444-1645",
        "authorized_official_name_prefix": "Mr.",
        "authorized_official_credential": "PA"
    },
    "taxonomies": [
        {
            "code": "363AS0400X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Physician Assistant, Surgical",
            "state": "NJ",
            "license": "25MP00262900",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Alicia Hettesheimer, RN
• Michelle E Hillock, LAC
• John Mena Hiras, DC
• Grace Fujia Huisking, PA-C
• Maureen Huntley, CHC AADP
• Inspire Wellness
• Intermedico LLC
• Kalista Concetta Javenes, OTR/L
• Jill Pharmacy Corp
• Jill Pharmacy Corp

• Surgical Physician Assistant in Glen Rock, NJ
• Providers in Glen Rock, NJ by specialty
• Surgical Physician Assistant in New Jersey

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 11, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.