| National Provider Identifier [NPI]: | 1427069889 |
| Last Name Of The Provider | LAKE |
| First Name Of The Provider | JACK |
| Middle Initial Of The Provider | F |
| Credentials Of The Provider | PA-C |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 2748 MILTON WAY |
| Street Address 2 Of The Provider | STE 101 |
| City Of The Provider | MILTON |
| Zip Code Of The Provider | 983549382 |
| State Code Of The Provider | WA |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Physician Assistant |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 44 |
| Number Of Services | 371 |
| Number Of Medicare Beneficiaries | 223 |
| Total Submitted Charge Amount | 51467 |
| Total Medicare Allowed Amount | 17571.71 |
| Total Medicare Payment Amount | 9114.91 |
| Total Medicare Standardized Payment Amount | 11730.69 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 7 |
| Number Of Drug Services | 30 |
| Number Of Medicare Beneficiaries With Drug Services | 11 |
| Total Drug Submitted ChargeAmount | 160 |
| Total Drug Medicare AllowedAmount | 55.35 |
| Total Drug Medicare PaymentAmount | 42.72 |
| Total Drug Medicare Standardized Payment Amount | 42.72 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 37 |
| Number Of Medical Services | 341 |
| Number Of Medicare Beneficiaries With Medical Services | 223 |
| Total Medical Submitted Charge Amount | 51307 |
| Total Medical Medicare Allowed Amount | 17516.36 |
| Total Medical Medicare Payment Amount | 9072.19 |
| Total Medical Medicare Standardized Payment Amount | 11687.97 |
| Average Age Of Beneficiaries | 73 |
| Number Of Beneficiaries Age Less65 | 22 |
| Number Of Beneficiaries Age 65 to 74 | 107 |
| Number Of Beneficiaries Age 75 to 84 | 62 |
| Number Of Beneficiaries Age Greater 84 | 32 |
| Number Of Female Beneficiaries | 147 |
| Number Of Male Beneficiaries | 76 |
| Number Of Non Hispanic White Beneficiaries | 206 |
| 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 | 208 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 15 |
| Percent Of With Atrial Fibrillation | 14 |
| Percent Of With Alzheimers Disease or Dementia | 9 |
| Percent Of With Asthma | 9 |
| Percent Of With Cancer | 12 |
| Percent Of With Heart Failure | 18 |
| Percent Of With Chronic Kidney Disease | 22 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 17 |
| Percent Of With Depression | 20 |
| Percent Of With Diabetes | 20 |
| Percent Of With Hyperlipidemia | 48 |
| Percent Of With Hypertension | 50 |
| Percent Of With Ischemic Heart Disease | 27 |
| Percent Of With Osteoporosis | 10 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 34 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | 6 |
| Average HCC Risk Score Of Beneficiaries | 0.989 |