| National Provider Identifier [NPI]: | 1205946613 |
| Last Name Of The Provider | PETERSON |
| First Name Of The Provider | SUSAN |
| Middle Initial Of The Provider | K |
| Credentials Of The Provider | PA |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 11143 PARKVIEW PLAZA DR |
| Street Address 2 Of The Provider | 100 |
| City Of The Provider | FORT WAYNE |
| Zip Code Of The Provider | 468451727 |
| State Code Of The Provider | IN |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Physician Assistant |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 14 |
| Number Of Services | 3937 |
| Number Of Medicare Beneficiaries | 35 |
| Total Submitted Charge Amount | 36260 |
| Total Medicare Allowed Amount | 16459.44 |
| Total Medicare Payment Amount | 12180.68 |
| Total Medicare Standardized Payment Amount | 13384.03 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 6 |
| Number Of Drug Services | 3883 |
| Number Of Medicare Beneficiaries With Drug Services | 12 |
| Total Drug Submitted ChargeAmount | 30090 |
| Total Drug Medicare AllowedAmount | 13865.38 |
| Total Drug Medicare PaymentAmount | 10870.45 |
| Total Drug Medicare Standardized Payment Amount | 10870.45 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 8 |
| Number Of Medical Services | 54 |
| Number Of Medicare Beneficiaries With Medical Services | 35 |
| Total Medical Submitted Charge Amount | 6170 |
| Total Medical Medicare Allowed Amount | 2594.06 |
| Total Medical Medicare Payment Amount | 1310.23 |
| Total Medical Medicare Standardized Payment Amount | 2513.58 |
| Average Age Of Beneficiaries | 68 |
| Number Of Beneficiaries Age Less65 | |
| Number Of Beneficiaries Age 65 to 74 | 20 |
| Number Of Beneficiaries Age 75 to 84 | |
| Number Of Beneficiaries Age Greater 84 | 0 |
| Number Of Female Beneficiaries | 19 |
| Number Of Male Beneficiaries | 16 |
| 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 | |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | |
| Percent Of With Atrial Fibrillation | |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | |
| Percent Of With Cancer | 51 |
| Percent Of With Heart Failure | |
| Percent Of With Chronic Kidney Disease | 37 |
| Percent Of With Chronic Obstructive Pulmonary Disease | |
| Percent Of With Depression | |
| Percent Of With Diabetes | |
| Percent Of With Hyperlipidemia | 37 |
| Percent Of With Hypertension | 51 |
| Percent Of With Ischemic Heart Disease | 31 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 2.0817 |