| National Provider Identifier [NPI]: | 1225213812 |
| Last Name Of The Provider | WAGNER |
| First Name Of The Provider | DONNELLE |
| Middle Initial Of The Provider | I |
| Credentials Of The Provider | DNP |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 3700 CLIFF DR |
| Street Address 2 Of The Provider | |
| City Of The Provider | FORT SMITH |
| Zip Code Of The Provider | 729035954 |
| State Code Of The Provider | AR |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Nurse Practitioner |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 12 |
| Number Of Services | 227 |
| Number Of Medicare Beneficiaries | 168 |
| Total Submitted Charge Amount | 40379 |
| Total Medicare Allowed Amount | 11918.49 |
| Total Medicare Payment Amount | 7339.18 |
| Total Medicare Standardized Payment Amount | 9136.91 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 0 |
| Number Of Drug Services | 0 |
| Number Of Medicare Beneficiaries With Drug Services | 0 |
| Total Drug Submitted ChargeAmount | 0 |
| Total Drug Medicare AllowedAmount | 0 |
| Total Drug Medicare PaymentAmount | 0 |
| Total Drug Medicare Standardized Payment Amount | 0 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 12 |
| Number Of Medical Services | 227 |
| Number Of Medicare Beneficiaries With Medical Services | 168 |
| Total Medical Submitted Charge Amount | 40379 |
| Total Medical Medicare Allowed Amount | 11918.49 |
| Total Medical Medicare Payment Amount | 7339.18 |
| Total Medical Medicare Standardized Payment Amount | 9136.91 |
| Average Age Of Beneficiaries | 73 |
| Number Of Beneficiaries Age Less65 | 32 |
| Number Of Beneficiaries Age 65 to 74 | 51 |
| Number Of Beneficiaries Age 75 to 84 | 57 |
| Number Of Beneficiaries Age Greater 84 | 28 |
| Number Of Female Beneficiaries | 98 |
| Number Of Male Beneficiaries | 70 |
| Number Of Non Hispanic White Beneficiaries | 152 |
| 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 | 0 |
| Number Of Beneficiaries With Medicare Only Entitlement | 132 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 36 |
| Percent Of With Atrial Fibrillation | 21 |
| Percent Of With Alzheimers Disease or Dementia | 15 |
| Percent Of With Asthma | 9 |
| Percent Of With Cancer | 8 |
| Percent Of With Heart Failure | 27 |
| Percent Of With Chronic Kidney Disease | 30 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 26 |
| Percent Of With Depression | 24 |
| Percent Of With Diabetes | 41 |
| Percent Of With Hyperlipidemia | 48 |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 35 |
| Percent Of With Osteoporosis | 8 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 35 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.5591 |