Basic Information
| Provider Information | |||||||||
| NPI: | 1265972715 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VAN DER LELIJ | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | JACOB HENDRIK | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 35380 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891335380 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207956183 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1669 W INA RD STE 141 | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857041981 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207956183 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2017 | ||||||||
| LastUpdateDate: | 09/17/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP9944 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.