Healthcare Provider Details

I. General information

NPI: 1275090292
Provider Name (Legal Business Name): EMILY BLOSSOM PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2019
Last Update Date: 10/17/2023
Certification Date: 10/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 WATERMAN DR
SOUTH PORTLAND ME
04106-3635
US

IV. Provider business mailing address

22 BRAMHALL ST
PORTLAND ME
04102-3134
US

V. Phone/Fax

Practice location:
  • Phone: 207-358-3188
  • Fax:
Mailing address:
  • Phone: 207-706-3280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2182
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: