| National Provider Identifier [NPI]: | 1467449835 |
| Last Name Of The Provider | STACKOW |
| First Name Of The Provider | LORI |
| Middle Initial Of The Provider | A |
| Credentials Of The Provider | PAC |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 2170 W IRONWOOD CENTER DR |
| Street Address 2 Of The Provider | SUITE A |
| City Of The Provider | COEUR D ALENE |
| Zip Code Of The Provider | 838142606 |
| State Code Of The Provider | ID |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Physician Assistant |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 24 |
| Number Of Services | 342 |
| Number Of Medicare Beneficiaries | 119 |
| Total Submitted Charge Amount | 32706 |
| Total Medicare Allowed Amount | 13837.01 |
| Total Medicare Payment Amount | 10046.82 |
| Total Medicare Standardized Payment Amount | 12953.11 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 4 |
| Number Of Drug Services | 22 |
| Number Of Medicare Beneficiaries With Drug Services | 14 |
| Total Drug Submitted ChargeAmount | 533 |
| Total Drug Medicare AllowedAmount | 429.82 |
| Total Drug Medicare PaymentAmount | 417.48 |
| Total Drug Medicare Standardized Payment Amount | 417.48 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 20 |
| Number Of Medical Services | 320 |
| Number Of Medicare Beneficiaries With Medical Services | 119 |
| Total Medical Submitted Charge Amount | 32173 |
| Total Medical Medicare Allowed Amount | 13407.19 |
| Total Medical Medicare Payment Amount | 9629.34 |
| Total Medical Medicare Standardized Payment Amount | 12535.63 |
| Average Age Of Beneficiaries | 71 |
| Number Of Beneficiaries Age Less65 | |
| Number Of Beneficiaries Age 65 to 74 | 82 |
| Number Of Beneficiaries Age 75 to 84 | |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 68 |
| Number Of Male Beneficiaries | 51 |
| 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 | |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | |
| Percent Of With Atrial Fibrillation | |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | |
| Percent Of With Cancer | 10 |
| Percent Of With Heart Failure | |
| Percent Of With Chronic Kidney Disease | |
| Percent Of With Chronic Obstructive Pulmonary Disease | |
| Percent Of With Depression | 20 |
| Percent Of With Diabetes | 24 |
| Percent Of With Hyperlipidemia | 44 |
| Percent Of With Hypertension | 52 |
| Percent Of With Ischemic Heart Disease | 18 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 31 |
| Percent Of With Schizophrenia Other PsychoticDisorders | 0 |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 0.6027 |