Healthcare Provider Details

I. General information

NPI: 1598347528
Provider Name (Legal Business Name): CONNOR CHAMBON VIECK PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2021
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1971 E BELTLINE AVE NE
GRAND RAPIDS MI
49525-7045
US

IV. Provider business mailing address

1971 E BELTLINE AVE NE
GRAND RAPIDS MI
49525-7045
US

V. Phone/Fax

Practice location:
  • Phone: 616-343-8175
  • Fax:
Mailing address:
  • Phone: 616-343-8175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: