Healthcare Provider Details

I. General information

NPI: 1497295901
Provider Name (Legal Business Name): WALLACE ADAM GOFORTH CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2017
Last Update Date: 10/09/2025
Certification Date: 10/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 W JACKSON ST
CARBONDALE IL
62901-1462
US

IV. Provider business mailing address

35 ALBANY RD STE C
CARBONDALE IL
62903-7647
US

V. Phone/Fax

Practice location:
  • Phone: 618-549-0721
  • Fax:
Mailing address:
  • Phone: 618-457-5111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1113831
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209016165
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041.449328
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number857695
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: