| National Provider Identifier [NPI]: | 1629080437 |
| Last Name Of The Provider | WIEGAND |
| First Name Of The Provider | SHANNON |
| Middle Initial Of The Provider | |
| Credentials Of The Provider | MD |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1717 W COWLES ST |
| Street Address 2 Of The Provider | CAIHC |
| City Of The Provider | FAIRBANKS |
| Zip Code Of The Provider | 99701 |
| State Code Of The Provider | AK |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 65 |
| Number Of Services | 815 |
| Number Of Medicare Beneficiaries | 104 |
| Total Submitted Charge Amount | 113998.83 |
| Total Medicare Allowed Amount | 35066.45 |
| Total Medicare Payment Amount | 26945.33 |
| Total Medicare Standardized Payment Amount | 22516.88 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 3 |
| Number Of Drug Services | 16 |
| Number Of Medicare Beneficiaries With Drug Services | 15 |
| Total Drug Submitted ChargeAmount | 176.11 |
| Total Drug Medicare AllowedAmount | 69.89 |
| Total Drug Medicare PaymentAmount | 68.49 |
| Total Drug Medicare Standardized Payment Amount | 68.49 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 62 |
| Number Of Medical Services | 799 |
| Number Of Medicare Beneficiaries With Medical Services | 104 |
| Total Medical Submitted Charge Amount | 113822.72 |
| Total Medical Medicare Allowed Amount | 34996.56 |
| Total Medical Medicare Payment Amount | 26876.84 |
| Total Medical Medicare Standardized Payment Amount | 22448.39 |
| Average Age Of Beneficiaries | 73 |
| Number Of Beneficiaries Age Less65 | 18 |
| Number Of Beneficiaries Age 65 to 74 | 33 |
| Number Of Beneficiaries Age 75 to 84 | 35 |
| Number Of Beneficiaries Age Greater 84 | 18 |
| Number Of Female Beneficiaries | 66 |
| Number Of Male Beneficiaries | 38 |
| 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 | 47 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 57 |
| Percent Of With Atrial Fibrillation | |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | |
| Percent Of With Cancer | 17 |
| Percent Of With Heart Failure | 20 |
| Percent Of With Chronic Kidney Disease | 18 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 18 |
| Percent Of With Depression | 17 |
| Percent Of With Diabetes | 33 |
| Percent Of With Hyperlipidemia | 41 |
| Percent Of With Hypertension | 72 |
| Percent Of With Ischemic Heart Disease | 29 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 34 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.1631 |