| National Provider Identifier [NPI]: | 1366752321 |
| Last Name Of The Provider | SAMPLE |
| First Name Of The Provider | JENNIFER |
| Middle Initial Of The Provider | L |
| Credentials Of The Provider | ARNP |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 483 N SEMORAN BLVD |
| Street Address 2 Of The Provider | SUITE 102 |
| City Of The Provider | WINTER PARK |
| Zip Code Of The Provider | 327923800 |
| State Code Of The Provider | FL |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Nurse Practitioner |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 7 |
| Number Of Services | 223 |
| Number Of Medicare Beneficiaries | 180 |
| Total Submitted Charge Amount | 54029 |
| Total Medicare Allowed Amount | 17047.8 |
| Total Medicare Payment Amount | 13211.58 |
| Total Medicare Standardized Payment Amount | 15374.38 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 0 |
| Number Of Drug Services | 0 |
| Number Of Medicare Beneficiaries With Drug Services | 0 |
| Total Drug Submitted ChargeAmount | 0 |
| Total Drug Medicare AllowedAmount | 0 |
| Total Drug Medicare PaymentAmount | 0 |
| Total Drug Medicare Standardized Payment Amount | 0 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 7 |
| Number Of Medical Services | 223 |
| Number Of Medicare Beneficiaries With Medical Services | 180 |
| Total Medical Submitted Charge Amount | 54029 |
| Total Medical Medicare Allowed Amount | 17047.8 |
| Total Medical Medicare Payment Amount | 13211.58 |
| Total Medical Medicare Standardized Payment Amount | 15374.38 |
| Average Age Of Beneficiaries | 74 |
| Number Of Beneficiaries Age Less65 | 37 |
| Number Of Beneficiaries Age 65 to 74 | 41 |
| Number Of Beneficiaries Age 75 to 84 | 57 |
| Number Of Beneficiaries Age Greater 84 | 45 |
| Number Of Female Beneficiaries | 107 |
| Number Of Male Beneficiaries | 73 |
| Number Of Non Hispanic White Beneficiaries | 104 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 44 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 118 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 62 |
| Percent Of With Atrial Fibrillation | 28 |
| Percent Of With Alzheimers Disease or Dementia | 47 |
| Percent Of With Asthma | 13 |
| Percent Of With Cancer | 16 |
| Percent Of With Heart Failure | 49 |
| Percent Of With Chronic Kidney Disease | 60 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 29 |
| Percent Of With Depression | 49 |
| Percent Of With Diabetes | 55 |
| Percent Of With Hyperlipidemia | 75 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 69 |
| Percent Of With Osteoporosis | 10 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 52 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 12 |
| Percent Of With Stroke | 49 |
| Average HCC Risk Score Of Beneficiaries | 2.5428 |