Healthcare Provider Details

I. General information

NPI: 1255710885
Provider Name (Legal Business Name): CHRISTOPHER L MYGATT PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2015
Last Update Date: 06/10/2025
Certification Date: 05/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 S 1ST ST
CHAMPAIGN IL
61820-7661
US

IV. Provider business mailing address

611 W PARK ST FAPC
URBANA IL
61801-2501
US

V. Phone/Fax

Practice location:
  • Phone: 217-383-9400
  • Fax: 217-383-9694
Mailing address:
  • Phone: 217-902-6954
  • Fax: 217-902-7711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number8555
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2023008003
License Number StateMO
# 4
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085005747
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: