Active NPI
Roman Matsouk, PA-C
- Surgical Physician Assistant
- Fairfield, NJ
National Provider Identifier
1558422766
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Surgical Physician Assistant
- License
- 011450-1
- Practice address
- 695 US Highway 46
Suite 400a
Fairfield, NJ 07004-1592 - Phone
- (973) 826-8080
- Fax
- (866) 309-3354
- NPI assigned
- Dec 12, 2006
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 3
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physician Assistant | 363A00000X | 2SMP00172500 | NJ | |
| Surgical Physician Assistant | 363AS0400X | 011450-1 | NY | Primary |
| Surgical Physician Assistant | 363AS0400X | 25MP00172500 | NJ |
Addresses
Primary practice location
695 US Highway 46
Suite 400a
Fairfield, NJ 07004-1592
Mailing address
PO Box 4059
Wayne, NJ 07474-4059
Phone (973) 826-8080
Other identifiers 3
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 116532ZJ5N | Other | NJ | PTAN SURGERY SERVICES |
| 0429294 | Medicaid | NJ | |
| 116532YP69 | Other | NJ | PTAN QUALITY SURGICAL SERVICES |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Physician Assistant
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 2SMP00172500 | NJ | MD | Physician Assistant |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1165881600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1558396800000",
"number": "1558422766",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 4059",
"city": "WAYNE",
"state": "NJ",
"postal_code": "074744059",
"telephone_number": "973-826-8080",
"fax_number": "866-309-3354"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "695 US HIGHWAY 46",
"address_2": "SUITE 400A",
"city": "FAIRFIELD",
"state": "NJ",
"postal_code": "070041592",
"telephone_number": "973-826-8080",
"fax_number": "866-309-3354"
}
],
"practiceLocations": [],
"basic": {
"last_name": "MATSOUK",
"first_name": "ROMAN",
"credential": "PA-C",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-12-12",
"last_updated": "2019-05-21",
"status": "A"
},
"taxonomies": [
{
"code": "363A00000X",
"taxonomy_group": "",
"desc": "Physician Assistant",
"state": "NJ",
"license": "2SMP00172500",
"primary": false
},
{
"code": "363AS0400X",
"taxonomy_group": "",
"desc": "Physician Assistant, Surgical",
"state": "NY",
"license": "011450-1",
"primary": true
},
{
"code": "363AS0400X",
"taxonomy_group": "",
"desc": "Physician Assistant, Surgical",
"state": "NJ",
"license": "25MP00172500",
"primary": false
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "PTAN SURGERY SERVICES",
"identifier": "116532ZJ5N",
"state": "NJ"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "0429294",
"state": "NJ"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "PTAN QUALITY SURGICAL SERVICES",
"identifier": "116532YP69",
"state": "NJ"
}
],
"endpoints": [],
"other_names": []
}Other providers in Fairfield, NJ
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 21, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.