NPIMap

Individual provider Active NPI

Autumn Nicole Malliard, PA-C

  • Physician Assistant
  • Du Bois, PA
National Provider Identifier
1003659020
Registry record updated Feb 3, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physician AssistantTaxonomy code 363A00000X
License
MA065595 Issued in PA
Practice address
145 Hospital Ave Ste 300
Du Bois, PA 15801-1465
Phone
(814) 375-2040
Fax
(814) 375-2045
NPI assigned
Jun 17, 2024
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Feb 3, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Surgical Physician Assistant 363AS0400X MA065595 PA
Physician Assistant 363A00000X MA065595 PA Primary

Addresses

Primary practice location

145 Hospital Ave Ste 300
Du Bois, PA 15801-1465

Mailing address

100 Hospital Ave
Du Bois, PA 15801-1440
Phone (814) 375-4200

Other names 1

  • Miss Autumn Nicole Blommen Former name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in PA
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20250205002922 PA Practitioner - Physician Assistant 8820528896 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 2024
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Dubois Regional Medical CenterGroup PAC ID 5890689715, 424 clinicians

Practice addresses (Care Compare)

100 Hospital Ave
Du Bois, PA 15801-1440
Phone (814) 375-2040

Hospital & facility affiliations

  • Penn Highlands Dubois Hospital, Dubois, PA, CCN 390086
  • Penn Highlands Elk Hospital, Saint Marys, PA, CCN 391315
  • Penn Highlands Brookville Hospital, Brookville, PA, CCN 391312

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

State licenses

LicenseStateTypeSpecialty
MA065595PAMDPhysician Assistant

Practice roles

OrganizationSpecialtyStatusNew patients
Dubois Regional Medical Center CurrentSince Dec 5, 2024 Accepting new patients
Dubois Regional Medical Center CurrentSince Dec 5, 2024 Accepting new patients
Dubois Regional Medical Center Physician Assistant Past Accepting new patients

Locations

100 Hospital Ave
Dubois, PA 15801
Phone (814) 375-2040

100 Hospital Ave
Ofc
Dubois, PA 15801

145 Hospital Ave
Ste 300
Dubois, PA 15801
Phone (814) 371-4524

Organizations & group practices 3

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 33

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

View all 33

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1718582400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1738540800000",
    "number": "1003659020",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "100 HOSPITAL AVE",
            "city": "DU BOIS",
            "state": "PA",
            "postal_code": "158011440",
            "telephone_number": "814-375-4200",
            "fax_number": "814-375-4232"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "145 HOSPITAL AVE STE 300",
            "city": "DU BOIS",
            "state": "PA",
            "postal_code": "158011465",
            "telephone_number": "814-375-2040",
            "fax_number": "814-375-2045"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "MALLIARD",
        "first_name": "AUTUMN",
        "middle_name": "NICOLE",
        "name_prefix": "Mrs.",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2024-06-17",
        "last_updated": "2025-02-03",
        "certification_date": "2025-02-03",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363AS0400X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Surgical",
            "state": "PA",
            "license": "MA065595",
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "PA",
            "license": "MA065595",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "AUTUMN",
            "last_name": "BLOMMEN",
            "middle_name": "NICOLE",
            "prefix": "MISS",
            "credential": "PA-C",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

Other providers in Du Bois, PA

Sources for this page

Verify at the official NPI Registry.