| National Provider Identifier [NPI]: | 1770769150 |
| Last Name Of The Provider | TAN |
| First Name Of The Provider | JACQUELINE |
| Middle Initial Of The Provider | S |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1875 WOODWINDS DR |
| Street Address 2 Of The Provider | |
| City Of The Provider | WOODBURY |
| Zip Code Of The Provider | 551252298 |
| State Code Of The Provider | MN |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 45 |
| Number Of Services | 532 |
| Number Of Medicare Beneficiaries | 102 |
| Total Submitted Charge Amount | 45202 |
| Total Medicare Allowed Amount | 20616.58 |
| Total Medicare Payment Amount | 14775.68 |
| Total Medicare Standardized Payment Amount | 15059.63 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 8 |
| Number Of Drug Services | 86 |
| Number Of Medicare Beneficiaries With Drug Services | 22 |
| Total Drug Submitted ChargeAmount | 2373 |
| Total Drug Medicare AllowedAmount | 1529.83 |
| Total Drug Medicare PaymentAmount | 1288.12 |
| Total Drug Medicare Standardized Payment Amount | 1288.12 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 37 |
| Number Of Medical Services | 446 |
| Number Of Medicare Beneficiaries With Medical Services | 102 |
| Total Medical Submitted Charge Amount | 42829 |
| Total Medical Medicare Allowed Amount | 19086.75 |
| Total Medical Medicare Payment Amount | 13487.56 |
| Total Medical Medicare Standardized Payment Amount | 13771.51 |
| Average Age Of Beneficiaries | 67 |
| Number Of Beneficiaries Age Less65 | 31 |
| Number Of Beneficiaries Age 65 to 74 | 38 |
| Number Of Beneficiaries Age 75 to 84 | |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 80 |
| Number Of Male Beneficiaries | 22 |
| Number Of Non Hispanic White Beneficiaries | 80 |
| 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 | 67 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 35 |
| 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 | |
| Percent Of With Chronic Kidney Disease | 17 |
| Percent Of With Chronic Obstructive Pulmonary Disease | |
| Percent Of With Depression | 25 |
| Percent Of With Diabetes | 16 |
| Percent Of With Hyperlipidemia | 24 |
| Percent Of With Hypertension | 44 |
| Percent Of With Ischemic Heart Disease | 18 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 25 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 0.9386 |