| National Provider Identifier [NPI]: | 1376579631 |
| Last Name Of The Provider | THIBEAULT |
| First Name Of The Provider | JUSTIN |
| Middle Initial Of The Provider | R |
| Credentials Of The Provider | PA-C |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1515 NW 18TH AVE |
| Street Address 2 Of The Provider | 3RD FLOOR |
| City Of The Provider | PORTLAND |
| Zip Code Of The Provider | 972092516 |
| State Code Of The Provider | OR |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Physician Assistant |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 55 |
| Number Of Services | 247 |
| Number Of Medicare Beneficiaries | 110 |
| Total Submitted Charge Amount | 76574.26 |
| Total Medicare Allowed Amount | 18172.28 |
| Total Medicare Payment Amount | 14090.64 |
| Total Medicare Standardized Payment Amount | 15056.8 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 4 |
| Number Of Drug Services | 67 |
| Number Of Medicare Beneficiaries With Drug Services | 16 |
| Total Drug Submitted ChargeAmount | 3201.37 |
| Total Drug Medicare AllowedAmount | 2473.85 |
| Total Drug Medicare PaymentAmount | 1932.54 |
| Total Drug Medicare Standardized Payment Amount | 1932.54 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 51 |
| Number Of Medical Services | 180 |
| Number Of Medicare Beneficiaries With Medical Services | 110 |
| Total Medical Submitted Charge Amount | 73372.89 |
| Total Medical Medicare Allowed Amount | 15698.43 |
| Total Medical Medicare Payment Amount | 12158.1 |
| Total Medical Medicare Standardized Payment Amount | 13124.26 |
| Average Age Of Beneficiaries | 70 |
| Number Of Beneficiaries Age Less65 | |
| Number Of Beneficiaries Age 65 to 74 | 47 |
| Number Of Beneficiaries Age 75 to 84 | 34 |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 64 |
| Number Of Male Beneficiaries | 46 |
| 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 | 91 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 19 |
| Percent Of With Atrial Fibrillation | 12 |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | 14 |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | 18 |
| Percent Of With Chronic Kidney Disease | 16 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 13 |
| Percent Of With Depression | 31 |
| Percent Of With Diabetes | 31 |
| Percent Of With Hyperlipidemia | 50 |
| Percent Of With Hypertension | 64 |
| Percent Of With Ischemic Heart Disease | 21 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 66 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 0.9055 |