| National Provider Identifier [NPI]: | 1699050617 |
| Last Name Of The Provider | NICHOLLS |
| First Name Of The Provider | DAN |
| Middle Initial Of The Provider | A |
| Credentials Of The Provider | PA-C |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 111 S 5TH ST |
| Street Address 2 Of The Provider | |
| City Of The Provider | DOUGLAS |
| Zip Code Of The Provider | 826332434 |
| State Code Of The Provider | WY |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Physician Assistant |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 54 |
| Number Of Services | 1563 |
| Number Of Medicare Beneficiaries | 208 |
| Total Submitted Charge Amount | 299589 |
| Total Medicare Allowed Amount | 78553.89 |
| Total Medicare Payment Amount | 58869.26 |
| Total Medicare Standardized Payment Amount | 63433.31 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 5 |
| Number Of Drug Services | 779 |
| Number Of Medicare Beneficiaries With Drug Services | 104 |
| Total Drug Submitted ChargeAmount | 55449 |
| Total Drug Medicare AllowedAmount | 31137.88 |
| Total Drug Medicare PaymentAmount | 24390.11 |
| Total Drug Medicare Standardized Payment Amount | 24390.11 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 49 |
| Number Of Medical Services | 784 |
| Number Of Medicare Beneficiaries With Medical Services | 208 |
| Total Medical Submitted Charge Amount | 244140 |
| Total Medical Medicare Allowed Amount | 47416.01 |
| Total Medical Medicare Payment Amount | 34479.15 |
| Total Medical Medicare Standardized Payment Amount | 39043.2 |
| Average Age Of Beneficiaries | 71 |
| Number Of Beneficiaries Age Less65 | 32 |
| Number Of Beneficiaries Age 65 to 74 | 98 |
| Number Of Beneficiaries Age 75 to 84 | 62 |
| Number Of Beneficiaries Age Greater 84 | 16 |
| Number Of Female Beneficiaries | 127 |
| Number Of Male Beneficiaries | 81 |
| 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 | 178 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 30 |
| Percent Of With Atrial Fibrillation | 10 |
| Percent Of With Alzheimers Disease or Dementia | 6 |
| Percent Of With Asthma | 6 |
| Percent Of With Cancer | 8 |
| Percent Of With Heart Failure | 12 |
| Percent Of With Chronic Kidney Disease | 9 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 13 |
| Percent Of With Depression | 21 |
| Percent Of With Diabetes | 19 |
| Percent Of With Hyperlipidemia | 36 |
| Percent Of With Hypertension | 57 |
| Percent Of With Ischemic Heart Disease | 29 |
| Percent Of With Osteoporosis | 10 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 71 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 0.91 |