| National Provider Identifier [NPI]: | 1497911556 |
| Last Name Of The Provider | PETERSEN |
| First Name Of The Provider | SHAUN |
| Middle Initial Of The Provider | M |
| Credentials Of The Provider | PA |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 2310 N 400 E |
| Street Address 2 Of The Provider | STE A |
| City Of The Provider | NORTH LOGAN |
| Zip Code Of The Provider | 843411788 |
| State Code Of The Provider | UT |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Physician Assistant |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 52 |
| Number Of Services | 343 |
| Number Of Medicare Beneficiaries | 105 |
| Total Submitted Charge Amount | 56006.83 |
| Total Medicare Allowed Amount | 17058.23 |
| Total Medicare Payment Amount | 13046.03 |
| Total Medicare Standardized Payment Amount | 14679.77 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 2 |
| Number Of Drug Services | 79 |
| Number Of Medicare Beneficiaries With Drug Services | 22 |
| Total Drug Submitted ChargeAmount | 3355 |
| Total Drug Medicare AllowedAmount | 2437.52 |
| Total Drug Medicare PaymentAmount | 1911.02 |
| Total Drug Medicare Standardized Payment Amount | 1911.02 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 50 |
| Number Of Medical Services | 264 |
| Number Of Medicare Beneficiaries With Medical Services | 105 |
| Total Medical Submitted Charge Amount | 52651.83 |
| Total Medical Medicare Allowed Amount | 14620.71 |
| Total Medical Medicare Payment Amount | 11135.01 |
| Total Medical Medicare Standardized Payment Amount | 12768.75 |
| Average Age Of Beneficiaries | 72 |
| Number Of Beneficiaries Age Less65 | 16 |
| Number Of Beneficiaries Age 65 to 74 | 51 |
| Number Of Beneficiaries Age 75 to 84 | 25 |
| Number Of Beneficiaries Age Greater 84 | 13 |
| Number Of Female Beneficiaries | 78 |
| Number Of Male Beneficiaries | 27 |
| 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 | 91 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 14 |
| Percent Of With Atrial Fibrillation | 14 |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | 10 |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | 11 |
| Percent Of With Chronic Kidney Disease | 15 |
| Percent Of With Chronic Obstructive Pulmonary Disease | |
| Percent Of With Depression | 37 |
| Percent Of With Diabetes | 30 |
| Percent Of With Hyperlipidemia | 43 |
| Percent Of With Hypertension | 60 |
| Percent Of With Ischemic Heart Disease | 19 |
| Percent Of With Osteoporosis | 17 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 69 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 0.9421 |