| National Provider Identifier [NPI]: | 1306979059 |
| Last Name Of The Provider | GREEN |
| First Name Of The Provider | WALLACE |
| Middle Initial Of The Provider | M |
| Credentials Of The Provider | PAC |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1275 HIGHWAY 54 W |
| Street Address 2 Of The Provider | STE.105 |
| City Of The Provider | FAYETTEVILLE |
| Zip Code Of The Provider | 302144549 |
| State Code Of The Provider | GA |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Physician Assistant |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 8 |
| Number Of Services | 199 |
| Number Of Medicare Beneficiaries | 110 |
| Total Submitted Charge Amount | 26655 |
| Total Medicare Allowed Amount | 10673.16 |
| Total Medicare Payment Amount | 8356.78 |
| Total Medicare Standardized Payment Amount | 9623.27 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 1 |
| Number Of Drug Services | 34 |
| Number Of Medicare Beneficiaries With Drug Services | 11 |
| Total Drug Submitted ChargeAmount | 850 |
| Total Drug Medicare AllowedAmount | 4.06 |
| Total Drug Medicare PaymentAmount | 3.19 |
| Total Drug Medicare Standardized Payment Amount | 3.19 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 7 |
| Number Of Medical Services | 165 |
| Number Of Medicare Beneficiaries With Medical Services | 110 |
| Total Medical Submitted Charge Amount | 25805 |
| Total Medical Medicare Allowed Amount | 10669.1 |
| Total Medical Medicare Payment Amount | 8353.59 |
| Total Medical Medicare Standardized Payment Amount | 9620.08 |
| Average Age Of Beneficiaries | 61 |
| Number Of Beneficiaries Age Less65 | 62 |
| Number Of Beneficiaries Age 65 to 74 | 36 |
| Number Of Beneficiaries Age 75 to 84 | |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 72 |
| Number Of Male Beneficiaries | 38 |
| Number Of Non Hispanic White Beneficiaries | 91 |
| 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 | 66 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 44 |
| Percent Of With Atrial Fibrillation | |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | 13 |
| Percent Of With Chronic Kidney Disease | 15 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 16 |
| Percent Of With Depression | 47 |
| Percent Of With Diabetes | 32 |
| Percent Of With Hyperlipidemia | 38 |
| Percent Of With Hypertension | 54 |
| Percent Of With Ischemic Heart Disease | 23 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 58 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.162 |