MEDICARE: EMILY BLOSSOM PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant
2	363A00000X	Physician Assistant	PA2182	ME

General Provider Information

NPI Number	:	1275090292
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EMILY BLOSSOM PA-C

Provider Business Mailing Address
First Line	:	22 BRAMHALL ST
Second Line	:
City	:	PORTLAND
State	:	ME
Zip	:	04102-3134
Country	:	US
Telephone Number	:	207-706-3280
Fax Number	:

Provider Business Practice Location Address
First Line	:	230 WATERMAN DR
Second Line	:
City	:	SOUTH PORTLAND
State	:	ME
Zip	:	04106-3635
Country	:	US
Telephone Number	:	207-358-3188
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/26/2019
Last Update Date	:	10/17/2023

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Directions to “ EMILY BLOSSOM PA-C” Practice Location

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