MEDICARE: MR. ZACHARY MICHAEL DEFOUW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AS0400X	Surgical Physician Assistant
2	363AM0700X	Medical Physician Assistant
3	363A00000X	Physician Assistant	PA67003	CA

General Provider Information

NPI Number	:	1346048717
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ZACHARY MICHAEL DEFOUW

Provider Business Mailing Address
First Line	:	1800 HAINES ST NW
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49504-3958
Country	:	US
Telephone Number	:	616-901-3242
Fax Number	:

Provider Business Practice Location Address
First Line	:	1800 HAINES ST NW
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49504-3958
Country	:	US
Telephone Number	:	616-901-3242
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/03/2025
Last Update Date	:	09/24/2025

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