| National Provider Identifier [NPI]: | 1043549918 |
| Last Name Of The Provider | STATEN |
| First Name Of The Provider | TEQUILA |
| Middle Initial Of The Provider | J |
| Credentials Of The Provider | ARNP |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1330 N RACE ST |
| Street Address 2 Of The Provider | |
| City Of The Provider | GLASGOW |
| Zip Code Of The Provider | 421413465 |
| State Code Of The Provider | KY |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Nurse Practitioner |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 67 |
| Number Of Services | 1175 |
| Number Of Medicare Beneficiaries | 155 |
| Total Submitted Charge Amount | 111198 |
| Total Medicare Allowed Amount | 53813.66 |
| Total Medicare Payment Amount | 41825.25 |
| Total Medicare Standardized Payment Amount | 52027.69 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 8 |
| Number Of Drug Services | 145 |
| Number Of Medicare Beneficiaries With Drug Services | 33 |
| Total Drug Submitted ChargeAmount | 3033 |
| Total Drug Medicare AllowedAmount | 297.37 |
| Total Drug Medicare PaymentAmount | 248.71 |
| Total Drug Medicare Standardized Payment Amount | 248.71 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 59 |
| Number Of Medical Services | 1030 |
| Number Of Medicare Beneficiaries With Medical Services | 155 |
| Total Medical Submitted Charge Amount | 108165 |
| Total Medical Medicare Allowed Amount | 53516.29 |
| Total Medical Medicare Payment Amount | 41576.54 |
| Total Medical Medicare Standardized Payment Amount | 51778.98 |
| Average Age Of Beneficiaries | 73 |
| Number Of Beneficiaries Age Less65 | 38 |
| Number Of Beneficiaries Age 65 to 74 | 45 |
| Number Of Beneficiaries Age 75 to 84 | 38 |
| Number Of Beneficiaries Age Greater 84 | 34 |
| Number Of Female Beneficiaries | 110 |
| Number Of Male Beneficiaries | 45 |
| Number Of Non Hispanic White Beneficiaries | 144 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | 0 |
| Number Of Hispanic Beneficiaries | |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | 0 |
| Number Of Beneficiaries With Medicare Only Entitlement | 74 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 81 |
| Percent Of With Atrial Fibrillation | 14 |
| Percent Of With Alzheimers Disease or Dementia | 32 |
| Percent Of With Asthma | |
| Percent Of With Cancer | 7 |
| Percent Of With Heart Failure | 25 |
| Percent Of With Chronic Kidney Disease | 32 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 23 |
| Percent Of With Depression | 52 |
| Percent Of With Diabetes | 39 |
| Percent Of With Hyperlipidemia | 55 |
| Percent Of With Hypertension | 74 |
| Percent Of With Ischemic Heart Disease | 37 |
| Percent Of With Osteoporosis | 12 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 41 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 32 |
| Percent Of With Stroke | 9 |
| Average HCC Risk Score Of Beneficiaries | 1.275 |