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MR. BRIAN KEITH BONOMO PAC

>> Physician Assistant >> Physician Assistants & Advanced Practice Nursing Providers

Registrant NPI Number: 1124012596

Individual Registrant:
MR. BRIAN KEITH BONOMO PAC
Gender: M
Not Sole Proprietor

Location and contact information for practice:
525 N DACIE PT  LECANTO, FL 34461-8399 US
Tel: 352-746-2200  Fax: 352-746-9320

Contact information for business:
525 N DACIE PT  LECANTO, FL 34461-8399 US
Tel: 352-746-2200  Fax: 352-746-9320

Registration Information:
NPI: 1124012596
Entity Type: Individual

Specialty information:

PrimaryCodeCategory/DescriptionStateLicense Number
Y363A00000XPhysician Assistants & Advanced Practice Nursing Providers
Physician Assistant
FLPA9101264

Legacy codes, insurance codes and state license numbers:

IssuerNumberStateType
290989800FL05
SRRGA970015048FL01




HEALTH CARE JOBS FL - Page 1



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