Provider Demographics
NPI:1558422766
Name:MATSOUK, ROMAN (PA-C)
Entity Type:Individual
Prefix:
First Name:ROMAN
Middle Name:
Last Name:MATSOUK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4059
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07474-4059
Mailing Address - Country:US
Mailing Address - Phone:973-826-8080
Mailing Address - Fax:866-309-3354
Practice Address - Street 1:695 US HIGHWAY 46
Practice Address - Street 2:SUITE 400A
Practice Address - City:FAIRFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07004-1592
Practice Address - Country:US
Practice Address - Phone:973-826-8080
Practice Address - Fax:866-309-3354
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ2SMP00172500363A00000X
NY011450-1363AS0400X
NJ25MP00172500363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ116532ZJ5NOtherPTAN SURGERY SERVICES
NJ0429294Medicaid
NJ116532YP69OtherPTAN QUALITY SURGICAL SERVICES
NJ116532ZJ5NOtherPTAN SURGERY SERVICES
NJ0429294Medicaid