| National Provider Identifier [NPI]: | 1639220080 |
| Last Name Of The Provider | WANNER |
| First Name Of The Provider | MICHELLE |
| Middle Initial Of The Provider | A |
| Credentials Of The Provider | PA-C |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 4656 EXCELSIOR BLVD |
| Street Address 2 Of The Provider | |
| City Of The Provider | SAINT LOUIS PARK |
| Zip Code Of The Provider | 554164938 |
| State Code Of The Provider | MN |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Physician Assistant |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 14 |
| Number Of Services | 87 |
| Number Of Medicare Beneficiaries | 56 |
| Total Submitted Charge Amount | 4246.75 |
| Total Medicare Allowed Amount | 3759.62 |
| Total Medicare Payment Amount | 2769.12 |
| Total Medicare Standardized Payment Amount | 3291.96 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 3 |
| Number Of Drug Services | 25 |
| Number Of Medicare Beneficiaries With Drug Services | 24 |
| Total Drug Submitted ChargeAmount | 767.75 |
| Total Drug Medicare AllowedAmount | 767.75 |
| Total Drug Medicare PaymentAmount | 722.02 |
| Total Drug Medicare Standardized Payment Amount | 722.02 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 11 |
| Number Of Medical Services | 62 |
| Number Of Medicare Beneficiaries With Medical Services | 56 |
| Total Medical Submitted Charge Amount | 3479 |
| Total Medical Medicare Allowed Amount | 2991.87 |
| Total Medical Medicare Payment Amount | 2047.1 |
| Total Medical Medicare Standardized Payment Amount | 2569.94 |
| Average Age Of Beneficiaries | 69 |
| Number Of Beneficiaries Age Less65 | |
| Number Of Beneficiaries Age 65 to 74 | 35 |
| Number Of Beneficiaries Age 75 to 84 | |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 38 |
| Number Of Male Beneficiaries | 18 |
| 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 | |
| Percent Of With Heart Failure | |
| Percent Of With Chronic Kidney Disease | 0 |
| Percent Of With Chronic Obstructive Pulmonary Disease | |
| Percent Of With Depression | 20 |
| Percent Of With Diabetes | |
| Percent Of With Hyperlipidemia | 20 |
| Percent Of With Hypertension | 20 |
| Percent Of With Ischemic Heart Disease | |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | 0 |
| Average HCC Risk Score Of Beneficiaries | 0.644 |