| National Provider Identifier [NPI]: | 1114231628 |
| Last Name Of The Provider | WIVHOLM |
| First Name Of The Provider | BROOKE |
| Middle Initial Of The Provider | D |
| Credentials Of The Provider | PA-C |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1075 MASON AVE |
| Street Address 2 Of The Provider | |
| City Of The Provider | DAYTONA BEACH |
| Zip Code Of The Provider | 32117 |
| State Code Of The Provider | FL |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Physician Assistant |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 68 |
| Number Of Services | 616 |
| Number Of Medicare Beneficiaries | 189 |
| Total Submitted Charge Amount | 280057.5 |
| Total Medicare Allowed Amount | 30544.31 |
| Total Medicare Payment Amount | 23459.46 |
| Total Medicare Standardized Payment Amount | 25580.93 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 2 |
| Number Of Drug Services | 101 |
| Number Of Medicare Beneficiaries With Drug Services | 35 |
| Total Drug Submitted ChargeAmount | 2241 |
| Total Drug Medicare AllowedAmount | 497.38 |
| Total Drug Medicare PaymentAmount | 374.19 |
| Total Drug Medicare Standardized Payment Amount | 374.19 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 66 |
| Number Of Medical Services | 515 |
| Number Of Medicare Beneficiaries With Medical Services | 189 |
| Total Medical Submitted Charge Amount | 277816.5 |
| Total Medical Medicare Allowed Amount | 30046.93 |
| Total Medical Medicare Payment Amount | 23085.27 |
| Total Medical Medicare Standardized Payment Amount | 25206.74 |
| Average Age Of Beneficiaries | 74 |
| Number Of Beneficiaries Age Less65 | 24 |
| Number Of Beneficiaries Age 65 to 74 | 69 |
| Number Of Beneficiaries Age 75 to 84 | 73 |
| Number Of Beneficiaries Age Greater 84 | 23 |
| Number Of Female Beneficiaries | 109 |
| Number Of Male Beneficiaries | 80 |
| Number Of Non Hispanic White Beneficiaries | 170 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 165 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 24 |
| Percent Of With Atrial Fibrillation | 15 |
| Percent Of With Alzheimers Disease or Dementia | 10 |
| Percent Of With Asthma | 7 |
| Percent Of With Cancer | 12 |
| Percent Of With Heart Failure | 19 |
| Percent Of With Chronic Kidney Disease | 25 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 23 |
| Percent Of With Depression | 22 |
| Percent Of With Diabetes | 28 |
| Percent Of With Hyperlipidemia | 73 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 43 |
| Percent Of With Osteoporosis | 60 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 75 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | 7 |
| Average HCC Risk Score Of Beneficiaries | 1.1954 |