| National Provider Identifier [NPI]: | 1700122587 |
| Last Name Of The Provider | DEBOLT |
| First Name Of The Provider | NICHOLAS |
| Middle Initial Of The Provider | D |
| Credentials Of The Provider | PA-C |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1125 E CLEVELAND AVE |
| Street Address 2 Of The Provider | |
| City Of The Provider | SAPULPA |
| Zip Code Of The Provider | 740664641 |
| State Code Of The Provider | OK |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Physician Assistant |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 77 |
| Number Of Services | 810 |
| Number Of Medicare Beneficiaries | 86 |
| Total Submitted Charge Amount | 78927.33 |
| Total Medicare Allowed Amount | 19038.66 |
| Total Medicare Payment Amount | 14361.8 |
| Total Medicare Standardized Payment Amount | 17301.64 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 7 |
| Number Of Drug Services | 114 |
| Number Of Medicare Beneficiaries With Drug Services | 25 |
| Total Drug Submitted ChargeAmount | 1184.61 |
| Total Drug Medicare AllowedAmount | 283.94 |
| Total Drug Medicare PaymentAmount | 252.6 |
| Total Drug Medicare Standardized Payment Amount | 252.6 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 70 |
| Number Of Medical Services | 696 |
| Number Of Medicare Beneficiaries With Medical Services | 86 |
| Total Medical Submitted Charge Amount | 77742.72 |
| Total Medical Medicare Allowed Amount | 18754.72 |
| Total Medical Medicare Payment Amount | 14109.2 |
| Total Medical Medicare Standardized Payment Amount | 17049.04 |
| Average Age Of Beneficiaries | 68 |
| Number Of Beneficiaries Age Less65 | 25 |
| Number Of Beneficiaries Age 65 to 74 | 41 |
| Number Of Beneficiaries Age 75 to 84 | |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 40 |
| Number Of Male Beneficiaries | 46 |
| Number Of Non Hispanic White Beneficiaries | |
| 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 | 67 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 19 |
| Percent Of With Atrial Fibrillation | |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | 20 |
| Percent Of With Chronic Kidney Disease | 27 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 15 |
| Percent Of With Depression | 19 |
| Percent Of With Diabetes | 47 |
| Percent Of With Hyperlipidemia | 42 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 27 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 30 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.0954 |