| National Provider Identifier [NPI]: | 1629005749 |
| Last Name Of The Provider | HATHAWAY |
| First Name Of The Provider | NICKOLINE |
| Middle Initial Of The Provider | M |
| Credentials Of The Provider | MD |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 152 PIONEER LN |
| Street Address 2 Of The Provider | SUITE C |
| City Of The Provider | BISHOP |
| Zip Code Of The Provider | 935142563 |
| State Code Of The Provider | CA |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Internal Medicine |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 46 |
| Number Of Services | 2991 |
| Number Of Medicare Beneficiaries | 601 |
| Total Submitted Charge Amount | 252035.4 |
| Total Medicare Allowed Amount | 180140.99 |
| Total Medicare Payment Amount | 124980.07 |
| Total Medicare Standardized Payment Amount | 120257.5 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 7 |
| Number Of Drug Services | 232 |
| Number Of Medicare Beneficiaries With Drug Services | 198 |
| Total Drug Submitted ChargeAmount | 4212.02 |
| Total Drug Medicare AllowedAmount | 4067.67 |
| Total Drug Medicare PaymentAmount | 3966.67 |
| Total Drug Medicare Standardized Payment Amount | 3966.67 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 39 |
| Number Of Medical Services | 2759 |
| Number Of Medicare Beneficiaries With Medical Services | 601 |
| Total Medical Submitted Charge Amount | 247823.38 |
| Total Medical Medicare Allowed Amount | 176073.32 |
| Total Medical Medicare Payment Amount | 121013.4 |
| Total Medical Medicare Standardized Payment Amount | 116290.83 |
| Average Age Of Beneficiaries | 76 |
| Number Of Beneficiaries Age Less65 | 48 |
| Number Of Beneficiaries Age 65 to 74 | 224 |
| Number Of Beneficiaries Age 75 to 84 | 200 |
| Number Of Beneficiaries Age Greater 84 | 129 |
| Number Of Female Beneficiaries | 370 |
| Number Of Male Beneficiaries | 231 |
| Number Of Non Hispanic White Beneficiaries | 553 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | |
| Number Of American Indian Alaska Native Beneficiaries | 25 |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 495 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 106 |
| Percent Of With Atrial Fibrillation | 15 |
| Percent Of With Alzheimers Disease or Dementia | 11 |
| Percent Of With Asthma | 6 |
| Percent Of With Cancer | 10 |
| Percent Of With Heart Failure | 24 |
| Percent Of With Chronic Kidney Disease | 20 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 17 |
| Percent Of With Depression | 15 |
| Percent Of With Diabetes | 23 |
| Percent Of With Hyperlipidemia | 37 |
| Percent Of With Hypertension | 71 |
| Percent Of With Ischemic Heart Disease | 30 |
| Percent Of With Osteoporosis | 9 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 44 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 4 |
| Percent Of With Stroke | 5 |
| Average HCC Risk Score Of Beneficiaries | 1.0867 |