| National Provider Identifier [NPI]: | 1255329967 |
| Last Name Of The Provider | FERNSTROM |
| First Name Of The Provider | BRUCE |
| Middle Initial Of The Provider | |
| Credentials Of The Provider | PA |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 10000 SE MAIN ST |
| Street Address 2 Of The Provider | SUITE 342 |
| City Of The Provider | PORTLAND |
| Zip Code Of The Provider | 972162448 |
| State Code Of The Provider | OR |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Physician Assistant |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 30 |
| Number Of Services | 104 |
| Number Of Medicare Beneficiaries | 54 |
| Total Submitted Charge Amount | 38928.44 |
| Total Medicare Allowed Amount | 9863.33 |
| Total Medicare Payment Amount | 7386.44 |
| Total Medicare Standardized Payment Amount | 7967.02 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 3 |
| Number Of Drug Services | 20 |
| Number Of Medicare Beneficiaries With Drug Services | 11 |
| Total Drug Submitted ChargeAmount | 1563.44 |
| Total Drug Medicare AllowedAmount | 909.97 |
| Total Drug Medicare PaymentAmount | 713.42 |
| Total Drug Medicare Standardized Payment Amount | 713.42 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 27 |
| Number Of Medical Services | 84 |
| Number Of Medicare Beneficiaries With Medical Services | 54 |
| Total Medical Submitted Charge Amount | 37365 |
| Total Medical Medicare Allowed Amount | 8953.36 |
| Total Medical Medicare Payment Amount | 6673.02 |
| Total Medical Medicare Standardized Payment Amount | 7253.6 |
| Average Age Of Beneficiaries | 67 |
| Number Of Beneficiaries Age Less65 | 16 |
| Number Of Beneficiaries Age 65 to 74 | 19 |
| Number Of Beneficiaries Age 75 to 84 | |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 18 |
| Number Of Male Beneficiaries | 36 |
| Number Of Non Hispanic White Beneficiaries | |
| 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 | 37 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 17 |
| Percent Of With Atrial Fibrillation | |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | |
| Percent Of With Cancer | 30 |
| Percent Of With Heart Failure | 26 |
| Percent Of With Chronic Kidney Disease | 59 |
| Percent Of With Chronic Obstructive Pulmonary Disease | |
| Percent Of With Depression | 26 |
| Percent Of With Diabetes | 26 |
| Percent Of With Hyperlipidemia | 61 |
| Percent Of With Hypertension | 70 |
| Percent Of With Ischemic Heart Disease | 39 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 26 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | 0 |
| Average HCC Risk Score Of Beneficiaries | 3.1963 |