Provider Demographics
NPI:1457503823
Name:WILSON, CLIFFORD C (ANP)
Entity Type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:C
Last Name:WILSON
Suffix:
Gender:M
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4501 DIPLOMACY DR
Mailing Address - Street 2:ATTN: PROVIDER ENROLLMENT SERVICES
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5919
Mailing Address - Country:US
Mailing Address - Phone:907-729-8624
Mailing Address - Fax:
Practice Address - Street 1:4320 DIPLOMACY DR
Practice Address - Street 2:SUITE 1500
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5925
Practice Address - Country:US
Practice Address - Phone:907-729-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-16
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1055363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKNP0064Medicaid