| National Provider Identifier [NPI]: | 1801973615 |
| Last Name Of The Provider | MACK |
| First Name Of The Provider | CHARISSE |
| Middle Initial Of The Provider | L |
| Credentials Of The Provider | PA |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 6140 CURTISIAN AVE |
| Street Address 2 Of The Provider | STE 400 |
| City Of The Provider | BOISE |
| Zip Code Of The Provider | 837048880 |
| 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 | 37 |
| Number Of Services | 302 |
| Number Of Medicare Beneficiaries | 116 |
| Total Submitted Charge Amount | 754122.5 |
| Total Medicare Allowed Amount | 30696.92 |
| Total Medicare Payment Amount | 23093.8 |
| Total Medicare Standardized Payment Amount | 26506.14 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 0 |
| Number Of Drug Services | 0 |
| Number Of Medicare Beneficiaries With Drug Services | 0 |
| Total Drug Submitted ChargeAmount | 0 |
| Total Drug Medicare AllowedAmount | 0 |
| Total Drug Medicare PaymentAmount | 0 |
| Total Drug Medicare Standardized Payment Amount | 0 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 37 |
| Number Of Medical Services | 302 |
| Number Of Medicare Beneficiaries With Medical Services | 116 |
| Total Medical Submitted Charge Amount | 754122.5 |
| Total Medical Medicare Allowed Amount | 30696.92 |
| Total Medical Medicare Payment Amount | 23093.8 |
| Total Medical Medicare Standardized Payment Amount | 26506.14 |
| Average Age Of Beneficiaries | 69 |
| Number Of Beneficiaries Age Less65 | 25 |
| Number Of Beneficiaries Age 65 to 74 | 61 |
| Number Of Beneficiaries Age 75 to 84 | |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 59 |
| Number Of Male Beneficiaries | 57 |
| 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 | 96 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 20 |
| Percent Of With Atrial Fibrillation | |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | |
| Percent Of With Cancer | 11 |
| Percent Of With Heart Failure | |
| Percent Of With Chronic Kidney Disease | 20 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 14 |
| Percent Of With Depression | 43 |
| Percent Of With Diabetes | 16 |
| Percent Of With Hyperlipidemia | 53 |
| Percent Of With Hypertension | 59 |
| Percent Of With Ischemic Heart Disease | 16 |
| Percent Of With Osteoporosis | 16 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 75 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 0.9002 |