| National Provider Identifier [NPI]: | 1407965320 |
| Last Name Of The Provider | WALLACE |
| First Name Of The Provider | KATHRYN |
| Middle Initial Of The Provider | M |
| Credentials Of The Provider | APRN, BC |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 2640 HAMSTROM RD |
| Street Address 2 Of The Provider | |
| City Of The Provider | PORTAGE |
| Zip Code Of The Provider | 463683832 |
| State Code Of The Provider | IN |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Nurse Practitioner |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 10 |
| Number Of Services | 493 |
| Number Of Medicare Beneficiaries | 188 |
| Total Submitted Charge Amount | 52640 |
| Total Medicare Allowed Amount | 35756.88 |
| Total Medicare Payment Amount | 21470.03 |
| Total Medicare Standardized Payment Amount | 28650.69 |
| Drug Suppress Indicator | * |
| Number Of HCPCS Associated With Drug Services | |
| Number Of Drug Services | |
| Number Of Medicare Beneficiaries With Drug Services | |
| Total Drug Submitted ChargeAmount | |
| Total Drug Medicare AllowedAmount | |
| Total Drug Medicare PaymentAmount | |
| Total Drug Medicare Standardized Payment Amount | |
| Medical SuppressIndicator | # |
| Number Of HCPCS Associated With MedicalServices | |
| Number Of Medical Services | |
| Number Of Medicare Beneficiaries With Medical Services | |
| Total Medical Submitted Charge Amount | |
| Total Medical Medicare Allowed Amount | |
| Total Medical Medicare Payment Amount | |
| Total Medical Medicare Standardized Payment Amount | |
| Average Age Of Beneficiaries | 62 |
| Number Of Beneficiaries Age Less65 | 95 |
| Number Of Beneficiaries Age 65 to 74 | 52 |
| Number Of Beneficiaries Age 75 to 84 | 30 |
| Number Of Beneficiaries Age Greater 84 | 11 |
| Number Of Female Beneficiaries | 123 |
| Number Of Male Beneficiaries | 65 |
| Number Of Non Hispanic White Beneficiaries | 148 |
| Number Of Black or African American Beneficiaries | 19 |
| 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 | 98 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 90 |
| Percent Of With Atrial Fibrillation | |
| Percent Of With Alzheimers Disease or Dementia | 10 |
| Percent Of With Asthma | 13 |
| Percent Of With Cancer | 6 |
| Percent Of With Heart Failure | 24 |
| Percent Of With Chronic Kidney Disease | 24 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 36 |
| Percent Of With Depression | 36 |
| Percent Of With Diabetes | 35 |
| Percent Of With Hyperlipidemia | 36 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 22 |
| Percent Of With Osteoporosis | 7 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 40 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 7 |
| Percent Of With Stroke | 6 |
| Average HCC Risk Score Of Beneficiaries | 1.4325 |