MEDICARE: ADAM K WALLACE CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist	209183	WI
2	367500000X	Certified Registered Nurse Anesthetist	1-083374	AL

General Provider Information

NPI Number	:	1235450297
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ADAM K WALLACE CRNA

Provider Business Mailing Address
First Line	:	616 19TH ST
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31901-1528
Country	:	US
Telephone Number	:	706-494-4262
Fax Number	:

Provider Business Practice Location Address
First Line	:	600 HIGHLAND AVE
Second Line	:
City	:	MADISON
State	:	WI
Zip	:	53792-1528
Country	:	US
Telephone Number	:	608-263-8100
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/14/2010
Last Update Date	:	02/05/2025

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