Provider Demographics
NPI:1003659020
Name:MALLIARD, AUTUMN NICOLE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:AUTUMN
Middle Name:NICOLE
Last Name:MALLIARD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:AUTUMN
Other - Middle Name:NICOLE
Other - Last Name:BLOMMEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:100 HOSPITAL AVE
Mailing Address - Street 2:
Mailing Address - City:DU BOIS
Mailing Address - State:PA
Mailing Address - Zip Code:15801-1440
Mailing Address - Country:US
Mailing Address - Phone:814-375-4200
Mailing Address - Fax:814-375-4232
Practice Address - Street 1:145 HOSPITAL AVE STE 300
Practice Address - Street 2:
Practice Address - City:DU BOIS
Practice Address - State:PA
Practice Address - Zip Code:15801-1465
Practice Address - Country:US
Practice Address - Phone:814-375-2040
Practice Address - Fax:814-375-2045
Is Sole Proprietor?:No
Enumeration Date:2024-06-17
Last Update Date:2025-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA065595363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical