Provider Demographics
NPI:1154841831
Name:GOFORTH, JAMES ERIC (CRNP)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:ERIC
Last Name:GOFORTH
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 COUNTY ROAD 679
Mailing Address - Street 2:
Mailing Address - City:COFFEE SPRINGS
Mailing Address - State:AL
Mailing Address - Zip Code:36318-6051
Mailing Address - Country:US
Mailing Address - Phone:334-494-8485
Mailing Address - Fax:
Practice Address - Street 1:201 DOCTORS DR
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-2949
Practice Address - Country:US
Practice Address - Phone:334-794-6611
Practice Address - Fax:334-794-6614
Is Sole Proprietor?:No
Enumeration Date:2017-06-22
Last Update Date:2017-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-097156363LA2200X, 363LG0600X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology