Provider Demographics
NPI:1265972715
Name:VAN DER LELIJ, ERIC JACOB HENDRIK
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:JACOB HENDRIK
Last Name:VAN DER LELIJ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 35380
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-5380
Mailing Address - Country:US
Mailing Address - Phone:520-795-6183
Mailing Address - Fax:
Practice Address - Street 1:1669 W INA RD STE 101
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-1976
Practice Address - Country:US
Practice Address - Phone:520-795-6183
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-02
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP9944363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily