| National Provider Identifier [NPI]: | 1710094248 |
| Last Name Of The Provider | KENNEBECK |
| First Name Of The Provider | TISHA |
| Middle Initial Of The Provider | M |
| Credentials Of The Provider | PA-C |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 414 DOCTORS CT |
| Street Address 2 Of The Provider | |
| City Of The Provider | OSHKOSH |
| Zip Code Of The Provider | 54901 |
| State Code Of The Provider | WI |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Physician Assistant |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 37 |
| Number Of Services | 449 |
| Number Of Medicare Beneficiaries | 131 |
| Total Submitted Charge Amount | 87095.05 |
| Total Medicare Allowed Amount | 24982.29 |
| Total Medicare Payment Amount | 18102.02 |
| Total Medicare Standardized Payment Amount | 22247.54 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 12 |
| Number Of Drug Services | 59 |
| Number Of Medicare Beneficiaries With Drug Services | 28 |
| Total Drug Submitted ChargeAmount | 2122.05 |
| Total Drug Medicare AllowedAmount | 811.38 |
| Total Drug Medicare PaymentAmount | 782.35 |
| Total Drug Medicare Standardized Payment Amount | 782.35 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 25 |
| Number Of Medical Services | 390 |
| Number Of Medicare Beneficiaries With Medical Services | 131 |
| Total Medical Submitted Charge Amount | 84973 |
| Total Medical Medicare Allowed Amount | 24170.91 |
| Total Medical Medicare Payment Amount | 17319.67 |
| Total Medical Medicare Standardized Payment Amount | 21465.19 |
| Average Age Of Beneficiaries | 70 |
| Number Of Beneficiaries Age Less65 | 30 |
| Number Of Beneficiaries Age 65 to 74 | 47 |
| Number Of Beneficiaries Age 75 to 84 | 40 |
| Number Of Beneficiaries Age Greater 84 | 14 |
| Number Of Female Beneficiaries | 85 |
| 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 | 95 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 36 |
| Percent Of With Atrial Fibrillation | |
| Percent Of With Alzheimers Disease or Dementia | 8 |
| Percent Of With Asthma | 9 |
| Percent Of With Cancer | 8 |
| Percent Of With Heart Failure | 10 |
| Percent Of With Chronic Kidney Disease | 21 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 15 |
| Percent Of With Depression | 24 |
| Percent Of With Diabetes | 21 |
| Percent Of With Hyperlipidemia | 51 |
| Percent Of With Hypertension | 57 |
| Percent Of With Ischemic Heart Disease | 30 |
| Percent Of With Osteoporosis | 15 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 35 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.1097 |