| National Provider Identifier [NPI]: | 1093826497 |
| Last Name Of The Provider | WALLACE |
| First Name Of The Provider | SUSAN |
| Middle Initial Of The Provider | H |
| Credentials Of The Provider | APRN |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 16120 W DODGE RD |
| Street Address 2 Of The Provider | |
| City Of The Provider | OMAHA |
| Zip Code Of The Provider | 681182049 |
| State Code Of The Provider | NE |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Nurse Practitioner |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 89 |
| Number Of Services | 2405 |
| Number Of Medicare Beneficiaries | 622 |
| Total Submitted Charge Amount | 236961.17 |
| Total Medicare Allowed Amount | 87090.15 |
| Total Medicare Payment Amount | 64086.96 |
| Total Medicare Standardized Payment Amount | 80504.55 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 11 |
| Number Of Drug Services | 406 |
| Number Of Medicare Beneficiaries With Drug Services | 82 |
| Total Drug Submitted ChargeAmount | 13871 |
| Total Drug Medicare AllowedAmount | 6804.98 |
| Total Drug Medicare PaymentAmount | 5679.01 |
| Total Drug Medicare Standardized Payment Amount | 5679.01 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 78 |
| Number Of Medical Services | 1999 |
| Number Of Medicare Beneficiaries With Medical Services | 622 |
| Total Medical Submitted Charge Amount | 223090.17 |
| Total Medical Medicare Allowed Amount | 80285.17 |
| Total Medical Medicare Payment Amount | 58407.95 |
| Total Medical Medicare Standardized Payment Amount | 74825.54 |
| Average Age Of Beneficiaries | 75 |
| Number Of Beneficiaries Age Less65 | 23 |
| Number Of Beneficiaries Age 65 to 74 | 297 |
| Number Of Beneficiaries Age 75 to 84 | 204 |
| Number Of Beneficiaries Age Greater 84 | 98 |
| Number Of Female Beneficiaries | 381 |
| Number Of Male Beneficiaries | 241 |
| Number Of Non Hispanic White Beneficiaries | 595 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 0 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | 16 |
| Number Of Beneficiaries With Medicare Only Entitlement | 595 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 27 |
| Percent Of With Atrial Fibrillation | 14 |
| Percent Of With Alzheimers Disease or Dementia | 8 |
| Percent Of With Asthma | 7 |
| Percent Of With Cancer | 12 |
| Percent Of With Heart Failure | 12 |
| Percent Of With Chronic Kidney Disease | 16 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 14 |
| Percent Of With Depression | 14 |
| Percent Of With Diabetes | 21 |
| Percent Of With Hyperlipidemia | 41 |
| Percent Of With Hypertension | 54 |
| Percent Of With Ischemic Heart Disease | 26 |
| Percent Of With Osteoporosis | 8 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 42 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 2 |
| Percent Of With Stroke | 3 |
| Average HCC Risk Score Of Beneficiaries | 1.008 |