| National Provider Identifier [NPI]: | 1922436914 |
| Last Name Of The Provider | WALLACE |
| First Name Of The Provider | DONNETTA |
| Middle Initial Of The Provider | L |
| Credentials Of The Provider | |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1700 HIGHWAY 25 N |
| Street Address 2 Of The Provider | |
| City Of The Provider | BUFFALO |
| Zip Code Of The Provider | 553131930 |
| State Code Of The Provider | MN |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Nurse Practitioner |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 71 |
| Number Of Services | 474 |
| Number Of Medicare Beneficiaries | 112 |
| Total Submitted Charge Amount | 36742 |
| Total Medicare Allowed Amount | 15626.41 |
| Total Medicare Payment Amount | 11743.57 |
| Total Medicare Standardized Payment Amount | 13668.28 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 5 |
| Number Of Drug Services | 53 |
| Number Of Medicare Beneficiaries With Drug Services | 21 |
| Total Drug Submitted ChargeAmount | 869 |
| Total Drug Medicare AllowedAmount | 86.07 |
| Total Drug Medicare PaymentAmount | 81.57 |
| Total Drug Medicare Standardized Payment Amount | 81.57 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 66 |
| Number Of Medical Services | 421 |
| Number Of Medicare Beneficiaries With Medical Services | 112 |
| Total Medical Submitted Charge Amount | 35873 |
| Total Medical Medicare Allowed Amount | 15540.34 |
| Total Medical Medicare Payment Amount | 11662 |
| Total Medical Medicare Standardized Payment Amount | 13586.71 |
| Average Age Of Beneficiaries | 65 |
| Number Of Beneficiaries Age Less65 | 43 |
| Number Of Beneficiaries Age 65 to 74 | 30 |
| Number Of Beneficiaries Age 75 to 84 | 28 |
| Number Of Beneficiaries Age Greater 84 | 11 |
| Number Of Female Beneficiaries | 68 |
| Number Of Male Beneficiaries | 44 |
| 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 | 68 |
| 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 | 15 |
| Percent Of With Chronic Kidney Disease | 22 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 18 |
| Percent Of With Depression | 30 |
| Percent Of With Diabetes | 21 |
| Percent Of With Hyperlipidemia | 46 |
| Percent Of With Hypertension | 48 |
| Percent Of With Ischemic Heart Disease | 23 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 29 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 12 |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.0464 |