Individual
MR. BRIAN KEITH BONOMO
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PAC
Contact information
Practice address
525 N DACIE PT, LECANTO, FL 34461-8399
(352) 746-2200
(352) 746-9320
Mailing address
4651 VAN DYKE RD, LUTZ, FL 33558-4880
(813) 321-1786
(813) 321-1787
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA9101264
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
290989800
—
FL
01
—
970015048
SRRGA
FL
Enumeration date
08/31/2005
Last updated
11/12/2022
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