Basic Information
| Provider Information | |||||||||
| NPI: | 1912985334 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VAN DER LAAN | ||||||||
| FirstName: | PANCRAS | ||||||||
| MiddleName: | HENRY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 173 MIDDLE ST | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 035843508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037885029 | ||||||||
| FaxNumber: | 6037885607 | ||||||||
| Practice Location | |||||||||
| Address1: | 173 MIDDLE ST | ||||||||
| Address2: | |||||||||
| City: | LANCASTER | ||||||||
| State: | NH | ||||||||
| PostalCode: | 035843508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6037884911 | ||||||||
| FaxNumber: | 6037885031 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2006 | ||||||||
| LastUpdateDate: | 12/19/2018 | ||||||||
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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 | 207R00000X | 5728 | NH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00000540 | 05 | NH | MEDICAID | 0004272 | 05 | VT | MEDICAID |