Provider Demographics
NPI:1689330722
Name:GOMONIT, BRENT LLOYD
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:LLOYD
Last Name:GOMONIT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1833 CARDINAL LN
Mailing Address - Street 2:
Mailing Address - City:NAVARRE
Mailing Address - State:FL
Mailing Address - Zip Code:32566-8374
Mailing Address - Country:US
Mailing Address - Phone:850-225-0876
Mailing Address - Fax:
Practice Address - Street 1:235 W AIRPORT BLVD
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32505-2239
Practice Address - Country:US
Practice Address - Phone:185-085-7520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-12
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA31537225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant