| National Provider Identifier [NPI]: | 1952420333 |
| Last Name Of The Provider | GUSTAFSON-LARSON |
| First Name Of The Provider | ANN |
| Middle Initial Of The Provider | M |
| Credentials Of The Provider | RN, CNP |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1900 CENTRA CARE CIRCLE #2500 |
| Street Address 2 Of The Provider | CENTRA CARE CLINIC HEALTH PLAZA / ENDOCRINOLOGY |
| City Of The Provider | ST CLOUD |
| Zip Code Of The Provider | 563035000 |
| State Code Of The Provider | MN |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Nurse Practitioner |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 11 |
| Number Of Services | 227 |
| Number Of Medicare Beneficiaries | 87 |
| Total Submitted Charge Amount | 54642 |
| Total Medicare Allowed Amount | 19539.33 |
| Total Medicare Payment Amount | 13438.86 |
| Total Medicare Standardized Payment Amount | 16929.91 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 3 |
| Number Of Drug Services | 15 |
| Number Of Medicare Beneficiaries With Drug Services | 14 |
| Total Drug Submitted ChargeAmount | 648.75 |
| Total Drug Medicare AllowedAmount | 401.12 |
| Total Drug Medicare PaymentAmount | 390.82 |
| Total Drug Medicare Standardized Payment Amount | 390.82 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 8 |
| Number Of Medical Services | 212 |
| Number Of Medicare Beneficiaries With Medical Services | 87 |
| Total Medical Submitted Charge Amount | 53993.25 |
| Total Medical Medicare Allowed Amount | 19138.21 |
| Total Medical Medicare Payment Amount | 13048.04 |
| Total Medical Medicare Standardized Payment Amount | 16539.09 |
| Average Age Of Beneficiaries | 63 |
| Number Of Beneficiaries Age Less65 | 39 |
| Number Of Beneficiaries Age 65 to 74 | 29 |
| Number Of Beneficiaries Age 75 to 84 | |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 40 |
| Number Of Male Beneficiaries | 47 |
| 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 | 53 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 34 |
| 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 | 18 |
| Percent Of With Chronic Kidney Disease | 41 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 13 |
| Percent Of With Depression | 33 |
| Percent Of With Diabetes | 75 |
| Percent Of With Hyperlipidemia | 75 |
| Percent Of With Hypertension | 74 |
| Percent Of With Ischemic Heart Disease | 29 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 36 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.5543 |