| National Provider Identifier [NPI]: | 1649407040 |
| Last Name Of The Provider | HENRY |
| First Name Of The Provider | JESSE |
| Middle Initial Of The Provider | |
| Credentials Of The Provider | FNP |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1252 N 22ND ST UNIT B |
| Street Address 2 Of The Provider | |
| City Of The Provider | LARAMIE |
| Zip Code Of The Provider | 820725306 |
| State Code Of The Provider | WY |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Nurse Practitioner |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 21 |
| Number Of Services | 153 |
| Number Of Medicare Beneficiaries | 120 |
| Total Submitted Charge Amount | 57872 |
| Total Medicare Allowed Amount | 12106.26 |
| Total Medicare Payment Amount | 8952.58 |
| Total Medicare Standardized Payment Amount | 10537.03 |
| 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 | 21 |
| Number Of Medical Services | 153 |
| Number Of Medicare Beneficiaries With Medical Services | 120 |
| Total Medical Submitted Charge Amount | 57872 |
| Total Medical Medicare Allowed Amount | 12106.26 |
| Total Medical Medicare Payment Amount | 8952.58 |
| Total Medical Medicare Standardized Payment Amount | 10537.03 |
| Average Age Of Beneficiaries | 71 |
| Number Of Beneficiaries Age Less65 | 27 |
| Number Of Beneficiaries Age 65 to 74 | 39 |
| Number Of Beneficiaries Age 75 to 84 | 29 |
| Number Of Beneficiaries Age Greater 84 | 25 |
| Number Of Female Beneficiaries | 72 |
| Number Of Male Beneficiaries | 48 |
| Number Of Non Hispanic White Beneficiaries | 106 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| 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 | 83 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 37 |
| Percent Of With Atrial Fibrillation | 9 |
| Percent Of With Alzheimers Disease or Dementia | 16 |
| Percent Of With Asthma | 13 |
| Percent Of With Cancer | 10 |
| Percent Of With Heart Failure | 23 |
| Percent Of With Chronic Kidney Disease | 24 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 23 |
| Percent Of With Depression | 39 |
| Percent Of With Diabetes | 27 |
| Percent Of With Hyperlipidemia | 44 |
| Percent Of With Hypertension | 62 |
| Percent Of With Ischemic Heart Disease | 27 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 39 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 10 |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.3948 |