| National Provider Identifier [NPI]: | 1124015102 |
| Last Name Of The Provider | FULLER |
| First Name Of The Provider | CHUCK |
| Middle Initial Of The Provider | B |
| Credentials Of The Provider | PA-C |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 660 SHOSHONE ST E |
| Street Address 2 Of The Provider | SUITE 130 |
| City Of The Provider | TWIN FALLS |
| Zip Code Of The Provider | 833016110 |
| State Code Of The Provider | ID |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Physician Assistant |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 48 |
| Number Of Services | 529 |
| Number Of Medicare Beneficiaries | 319 |
| Total Submitted Charge Amount | 29323.35 |
| Total Medicare Allowed Amount | 23262 |
| Total Medicare Payment Amount | 14699.98 |
| Total Medicare Standardized Payment Amount | 19832.08 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 7 |
| Number Of Drug Services | 15 |
| Number Of Medicare Beneficiaries With Drug Services | 12 |
| Total Drug Submitted ChargeAmount | 124.35 |
| Total Drug Medicare AllowedAmount | 23.23 |
| Total Drug Medicare PaymentAmount | 18.35 |
| Total Drug Medicare Standardized Payment Amount | 18.35 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 41 |
| Number Of Medical Services | 514 |
| Number Of Medicare Beneficiaries With Medical Services | 319 |
| Total Medical Submitted Charge Amount | 29199 |
| Total Medical Medicare Allowed Amount | 23238.77 |
| Total Medical Medicare Payment Amount | 14681.63 |
| Total Medical Medicare Standardized Payment Amount | 19813.73 |
| Average Age Of Beneficiaries | 73 |
| Number Of Beneficiaries Age Less65 | 44 |
| Number Of Beneficiaries Age 65 to 74 | 122 |
| Number Of Beneficiaries Age 75 to 84 | 93 |
| Number Of Beneficiaries Age Greater 84 | 60 |
| Number Of Female Beneficiaries | 191 |
| Number Of Male Beneficiaries | 128 |
| Number Of Non Hispanic White Beneficiaries | 294 |
| 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 | 282 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 37 |
| Percent Of With Atrial Fibrillation | 10 |
| Percent Of With Alzheimers Disease or Dementia | 7 |
| Percent Of With Asthma | 4 |
| Percent Of With Cancer | 12 |
| Percent Of With Heart Failure | 10 |
| Percent Of With Chronic Kidney Disease | 14 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 10 |
| Percent Of With Depression | 22 |
| Percent Of With Diabetes | 19 |
| Percent Of With Hyperlipidemia | 38 |
| Percent Of With Hypertension | 54 |
| Percent Of With Ischemic Heart Disease | 19 |
| Percent Of With Osteoporosis | 8 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 32 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 4 |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 0.8322 |