| National Provider Identifier [NPI]: | 1396795514 |
| Last Name Of The Provider | LICUANAN |
| First Name Of The Provider | JESSE |
| Middle Initial Of The Provider | J |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 3300 SOUTH STREET |
| Street Address 2 Of The Provider | SUITE209 |
| City Of The Provider | LONG BEACH |
| Zip Code Of The Provider | 90805 |
| State Code Of The Provider | CA |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Internal Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 30 |
| Number Of Services | 2002 |
| Number Of Medicare Beneficiaries | 648 |
| Total Submitted Charge Amount | 258956.07 |
| Total Medicare Allowed Amount | 214364.84 |
| Total Medicare Payment Amount | 162581.39 |
| Total Medicare Standardized Payment Amount | 151726.2 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 1 |
| Number Of Drug Services | 11 |
| Number Of Medicare Beneficiaries With Drug Services | 11 |
| Total Drug Submitted ChargeAmount | 275 |
| Total Drug Medicare AllowedAmount | 169.4 |
| Total Drug Medicare PaymentAmount | 165.99 |
| Total Drug Medicare Standardized Payment Amount | 165.99 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 29 |
| Number Of Medical Services | 1991 |
| Number Of Medicare Beneficiaries With Medical Services | 648 |
| Total Medical Submitted Charge Amount | 258681.07 |
| Total Medical Medicare Allowed Amount | 214195.44 |
| Total Medical Medicare Payment Amount | 162415.4 |
| Total Medical Medicare Standardized Payment Amount | 151560.21 |
| Average Age Of Beneficiaries | 73 |
| Number Of Beneficiaries Age Less65 | 149 |
| Number Of Beneficiaries Age 65 to 74 | 183 |
| Number Of Beneficiaries Age 75 to 84 | 156 |
| Number Of Beneficiaries Age Greater 84 | 160 |
| Number Of Female Beneficiaries | 380 |
| Number Of Male Beneficiaries | 268 |
| Number Of Non Hispanic White Beneficiaries | 289 |
| Number Of Black or African American Beneficiaries | 137 |
| Number Of AsianPacific Islander Beneficiaries | 47 |
| Number Of Hispanic Beneficiaries | 161 |
| Number Of American Indian Alaska Native Beneficiaries | 0 |
| Number Of Beneficiaries With Race Not Else where Classified | 14 |
| Number Of Beneficiaries With Medicare Only Entitlement | 226 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 422 |
| Percent Of With Atrial Fibrillation | 14 |
| Percent Of With Alzheimers Disease or Dementia | 35 |
| Percent Of With Asthma | 15 |
| Percent Of With Cancer | 12 |
| Percent Of With Heart Failure | 44 |
| Percent Of With Chronic Kidney Disease | 47 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 31 |
| Percent Of With Depression | 32 |
| Percent Of With Diabetes | 48 |
| Percent Of With Hyperlipidemia | 57 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 49 |
| Percent Of With Osteoporosis | 11 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 46 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 17 |
| Percent Of With Stroke | 17 |
| Average HCC Risk Score Of Beneficiaries | 2.5464 |