| National Provider Identifier [NPI]: | 1669468260 |
| Last Name Of The Provider | WIDEMARK |
| First Name Of The Provider | ERICH |
| Middle Initial Of The Provider | A |
| Credentials Of The Provider | PHD, FNP-BC |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 14415 W MCDOWELL RD |
| Street Address 2 Of The Provider | GOODYEAR |
| City Of The Provider | GOODYEAR |
| Zip Code Of The Provider | 853952521 |
| State Code Of The Provider | AZ |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Nurse Practitioner |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 2 |
| Number Of Services | 29 |
| Number Of Medicare Beneficiaries | 25 |
| Total Submitted Charge Amount | 6375 |
| Total Medicare Allowed Amount | 4225.09 |
| Total Medicare Payment Amount | 3197.14 |
| Total Medicare Standardized Payment Amount | 3803.62 |
| 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 | 2 |
| Number Of Medical Services | 29 |
| Number Of Medicare Beneficiaries With Medical Services | 25 |
| Total Medical Submitted Charge Amount | 6375 |
| Total Medical Medicare Allowed Amount | 4225.09 |
| Total Medical Medicare Payment Amount | 3197.14 |
| Total Medical Medicare Standardized Payment Amount | 3803.62 |
| Average Age Of Beneficiaries | 43 |
| Number Of Beneficiaries Age Less65 | 25 |
| Number Of Beneficiaries Age 65 to 74 | 0 |
| Number Of Beneficiaries Age 75 to 84 | 0 |
| Number Of Beneficiaries Age Greater 84 | 0 |
| Number Of Female Beneficiaries | 11 |
| Number Of Male Beneficiaries | 14 |
| 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 | 0 |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | |
| Percent Of With Cancer | 0 |
| Percent Of With Heart Failure | |
| Percent Of With Chronic Kidney Disease | |
| Percent Of With Chronic Obstructive Pulmonary Disease | |
| Percent Of With Depression | 75 |
| Percent Of With Diabetes | |
| Percent Of With Hyperlipidemia | |
| Percent Of With Hypertension | 60 |
| Percent Of With Ischemic Heart Disease | |
| Percent Of With Osteoporosis | 0 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | |
| Percent Of With Schizophrenia Other PsychoticDisorders | 75 |
| Percent Of With Stroke | 0 |
| Average HCC Risk Score Of Beneficiaries | 1.6737 |