Healthcare Provider Details

I. General information

NPI: 1124012596
Provider Name (Legal Business Name): BRIAN KEITH BONOMO PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 11/12/2022
Certification Date: 11/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 N DACIE PT
LECANTO FL
34461-8399
US

IV. Provider business mailing address

4651 VAN DYKE RD
LUTZ FL
33558-4880
US

V. Phone/Fax

Practice location:
  • Phone: 352-746-2200
  • Fax: 352-746-9320
Mailing address:
  • Phone: 813-321-1786
  • Fax: 813-321-1787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9101264
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: