| National Provider Identifier [NPI]: | 1396736997 |
| Last Name Of The Provider | WALLACE |
| First Name Of The Provider | TASHA |
| Middle Initial Of The Provider | B |
| Credentials Of The Provider | D.O. |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 3400 LEE BLVD |
| Street Address 2 Of The Provider | SUITE 108 |
| City Of The Provider | LEHIGH ACRES |
| Zip Code Of The Provider | 339711309 |
| State Code Of The Provider | FL |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 42 |
| Number Of Services | 1264 |
| Number Of Medicare Beneficiaries | 221 |
| Total Submitted Charge Amount | 160080 |
| Total Medicare Allowed Amount | 85159.64 |
| Total Medicare Payment Amount | 59489.25 |
| Total Medicare Standardized Payment Amount | 58074.34 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 10 |
| Number Of Drug Services | 241 |
| Number Of Medicare Beneficiaries With Drug Services | 113 |
| Total Drug Submitted ChargeAmount | 8395 |
| Total Drug Medicare AllowedAmount | 3745.78 |
| Total Drug Medicare PaymentAmount | 3371.27 |
| Total Drug Medicare Standardized Payment Amount | 3371.27 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 32 |
| Number Of Medical Services | 1023 |
| Number Of Medicare Beneficiaries With Medical Services | 221 |
| Total Medical Submitted Charge Amount | 151685 |
| Total Medical Medicare Allowed Amount | 81413.86 |
| Total Medical Medicare Payment Amount | 56117.98 |
| Total Medical Medicare Standardized Payment Amount | 54703.07 |
| Average Age Of Beneficiaries | 70 |
| Number Of Beneficiaries Age Less65 | 42 |
| Number Of Beneficiaries Age 65 to 74 | 109 |
| Number Of Beneficiaries Age 75 to 84 | 52 |
| Number Of Beneficiaries Age Greater 84 | 18 |
| Number Of Female Beneficiaries | 133 |
| Number Of Male Beneficiaries | 88 |
| Number Of Non Hispanic White Beneficiaries | 177 |
| Number Of Black or African American Beneficiaries | 24 |
| 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 | 170 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 51 |
| Percent Of With Atrial Fibrillation | 6 |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | 8 |
| Percent Of With Cancer | 8 |
| Percent Of With Heart Failure | 12 |
| Percent Of With Chronic Kidney Disease | 14 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 14 |
| Percent Of With Depression | 22 |
| Percent Of With Diabetes | 29 |
| Percent Of With Hyperlipidemia | 63 |
| Percent Of With Hypertension | 67 |
| Percent Of With Ischemic Heart Disease | 27 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 24 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.0013 |