Healthcare Provider Details

I. General information

NPI: 1740249085
Provider Name (Legal Business Name): CHRISTIAN O MCMONIGAL JR. PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 04/01/2021
Certification Date: 04/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 ELK ST
COUDERSPORT PA
16915-9601
US

IV. Provider business mailing address

1001 E 2ND ST
COUDERSPORT PA
16915-8161
US

V. Phone/Fax

Practice location:
  • Phone: 814-274-5577
  • Fax: 814-274-8709
Mailing address:
  • Phone: 814-274-9300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA052309
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: