| National Provider Identifier [NPI]: | 1124006143 |
| Last Name Of The Provider | GUSTAFSON |
| First Name Of The Provider | LYNN |
| Middle Initial Of The Provider | K |
| Credentials Of The Provider | DPM |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1421 PREMIERE DR |
| Street Address 2 Of The Provider | MANKATO CLINIC @ WICKERSHAM CAMPUS |
| City Of The Provider | MANKATO |
| Zip Code Of The Provider | 56001 |
| State Code Of The Provider | MN |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Podiatry |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 46 |
| Number Of Services | 458 |
| Number Of Medicare Beneficiaries | 169 |
| Total Submitted Charge Amount | 96308.35 |
| Total Medicare Allowed Amount | 34632.25 |
| Total Medicare Payment Amount | 24472.38 |
| Total Medicare Standardized Payment Amount | 25479.14 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 2 |
| Number Of Drug Services | 68 |
| Number Of Medicare Beneficiaries With Drug Services | 12 |
| Total Drug Submitted ChargeAmount | 203.24 |
| Total Drug Medicare AllowedAmount | 11.06 |
| Total Drug Medicare PaymentAmount | 8.61 |
| Total Drug Medicare Standardized Payment Amount | 8.61 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 44 |
| Number Of Medical Services | 390 |
| Number Of Medicare Beneficiaries With Medical Services | 169 |
| Total Medical Submitted Charge Amount | 96105.11 |
| Total Medical Medicare Allowed Amount | 34621.19 |
| Total Medical Medicare Payment Amount | 24463.77 |
| Total Medical Medicare Standardized Payment Amount | 25470.53 |
| Average Age Of Beneficiaries | 67 |
| Number Of Beneficiaries Age Less65 | 62 |
| Number Of Beneficiaries Age 65 to 74 | 50 |
| Number Of Beneficiaries Age 75 to 84 | 39 |
| Number Of Beneficiaries Age Greater 84 | 18 |
| Number Of Female Beneficiaries | 113 |
| Number Of Male Beneficiaries | 56 |
| Number Of Non Hispanic White Beneficiaries | 158 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | 0 |
| Number Of Hispanic Beneficiaries | |
| Number Of American Indian Alaska Native Beneficiaries | 0 |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 112 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 57 |
| Percent Of With Atrial Fibrillation | 9 |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | 7 |
| Percent Of With Cancer | 7 |
| Percent Of With Heart Failure | 11 |
| Percent Of With Chronic Kidney Disease | 24 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 8 |
| Percent Of With Depression | 31 |
| Percent Of With Diabetes | 36 |
| Percent Of With Hyperlipidemia | 56 |
| Percent Of With Hypertension | 61 |
| Percent Of With Ischemic Heart Disease | 25 |
| Percent Of With Osteoporosis | 8 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 38 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 11 |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.2748 |