Individual
WALLACE ADAM GOFORTH
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CRNA
Contact information
Practice address
405 W JACKSON ST, CARBONDALE, IL 62901-1462
(618) 549-0721
Mailing address
35 ALBANY RD STE C, CARBONDALE, IL 62903-7647
(618) 457-5111
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
041.449328
IL
367500000X
Certified Registered Nurse Anesthetist
Primary
1113831
TX
367500000X
Certified Registered Nurse Anesthetist
209016165
IL
367500000X
Certified Registered Nurse Anesthetist
857695
NY
Other
Enumeration date
03/02/2017
Last updated
10/09/2025
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