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NPI Code Detail

MEDICARE: MR. BRIAN KEITH BONOMO PAC

MEDICARE: MR. BRIAN KEITH BONOMO PAC
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
1363A00000XPhysician AssistantPA9101264FL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1970015048OTHERFLSRRGA
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1124012596
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. BRIAN KEITH BONOMO PAC
Provider Business Mailing Address
First Line : 4651 VAN DYKE RD
Second Line :
City : LUTZ
State : FL
Zip : 33558-4880
Country : US
Telephone Number : 813-321-1786
Fax Number : 813-321-1787
Provider Business Practice Location Address
First Line : 525 N DACIE PT
Second Line :
City : LECANTO
State : FL
Zip : 34461-8399
Country : US
Telephone Number : 352-746-2200
Fax Number : 352-746-9320
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/31/2005
Last Update Date : 11/12/2022

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