Provider Demographics
NPI:1346048717
Name:DEFOUW, ZACHARY MICHAEL
Entity type:Individual
Prefix:MR
First Name:ZACHARY
Middle Name:MICHAEL
Last Name:DEFOUW
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 HAINES ST NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-3958
Mailing Address - Country:US
Mailing Address - Phone:616-901-3242
Mailing Address - Fax:
Practice Address - Street 1:1800 HAINES ST NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49504-3958
Practice Address - Country:US
Practice Address - Phone:616-901-3242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-03
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical