Provider Demographics
NPI:1518115971
Name:BLOSSOM, AMY PAXTON (MD)
Entity type:Individual
Prefix:DR
First Name:AMY
Middle Name:PAXTON
Last Name:BLOSSOM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:398 E MAIN ST STE 109
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38804-4039
Mailing Address - Country:US
Mailing Address - Phone:601-201-5673
Mailing Address - Fax:844-333-0389
Practice Address - Street 1:398 E MAIN ST STE 109
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38804-4039
Practice Address - Country:US
Practice Address - Phone:601-201-5673
Practice Address - Fax:844-333-0389
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-28
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS20261207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01186021Medicaid
MS512I160060Medicare PIN