| National Provider Identifier [NPI]: | 1922096239 |
| Last Name Of The Provider | GUSTAFSON |
| First Name Of The Provider | HOLLY |
| Middle Initial Of The Provider | S |
| Credentials Of The Provider | PAC |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1111 LEFFINGWELL AVE NE |
| Street Address 2 Of The Provider | STE 100 |
| City Of The Provider | GRAND RAPIDS |
| Zip Code Of The Provider | 495256406 |
| State Code Of The Provider | MI |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Physician Assistant |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 46 |
| Number Of Services | 1076 |
| Number Of Medicare Beneficiaries | 237 |
| Total Submitted Charge Amount | 834745.2 |
| Total Medicare Allowed Amount | 79200.49 |
| Total Medicare Payment Amount | 59325.59 |
| Total Medicare Standardized Payment Amount | 63610.94 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 4 |
| Number Of Drug Services | 372 |
| Number Of Medicare Beneficiaries With Drug Services | 70 |
| Total Drug Submitted ChargeAmount | 53793.2 |
| Total Drug Medicare AllowedAmount | 33367.62 |
| Total Drug Medicare PaymentAmount | 25818.94 |
| Total Drug Medicare Standardized Payment Amount | 25818.94 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 42 |
| Number Of Medical Services | 704 |
| Number Of Medicare Beneficiaries With Medical Services | 236 |
| Total Medical Submitted Charge Amount | 780952 |
| Total Medical Medicare Allowed Amount | 45832.87 |
| Total Medical Medicare Payment Amount | 33506.65 |
| Total Medical Medicare Standardized Payment Amount | 37792 |
| Average Age Of Beneficiaries | 74 |
| Number Of Beneficiaries Age Less65 | 18 |
| Number Of Beneficiaries Age 65 to 74 | 119 |
| Number Of Beneficiaries Age 75 to 84 | 71 |
| Number Of Beneficiaries Age Greater 84 | 29 |
| Number Of Female Beneficiaries | 160 |
| Number Of Male Beneficiaries | 77 |
| Number Of Non Hispanic White Beneficiaries | 220 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | 0 |
| 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 | 216 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 21 |
| Percent Of With Atrial Fibrillation | 11 |
| Percent Of With Alzheimers Disease or Dementia | 5 |
| Percent Of With Asthma | 9 |
| Percent Of With Cancer | 10 |
| Percent Of With Heart Failure | 11 |
| Percent Of With Chronic Kidney Disease | 20 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 7 |
| Percent Of With Depression | 28 |
| Percent Of With Diabetes | 23 |
| Percent Of With Hyperlipidemia | 61 |
| Percent Of With Hypertension | 73 |
| Percent Of With Ischemic Heart Disease | 27 |
| Percent Of With Osteoporosis | 12 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 75 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 0.9168 |