| National Provider Identifier [NPI]: | 1003879735 |
| Last Name Of The Provider | HENRY |
| First Name Of The Provider | TANISHA |
| Middle Initial Of The Provider | M |
| Credentials Of The Provider | PA |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 4500 SAN PABLO RD S |
| Street Address 2 Of The Provider | VINCENT STABILE BLDG 550N |
| City Of The Provider | JACKSONVILLE |
| Zip Code Of The Provider | 322241865 |
| State Code Of The Provider | FL |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Physician Assistant |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 3 |
| Number Of Services | 244 |
| Number Of Medicare Beneficiaries | 152 |
| Total Submitted Charge Amount | 31350.2 |
| Total Medicare Allowed Amount | 23198.64 |
| Total Medicare Payment Amount | 17083.46 |
| Total Medicare Standardized Payment Amount | 21577.1 |
| 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 | 3 |
| Number Of Medical Services | 244 |
| Number Of Medicare Beneficiaries With Medical Services | 152 |
| Total Medical Submitted Charge Amount | 31350.2 |
| Total Medical Medicare Allowed Amount | 23198.64 |
| Total Medical Medicare Payment Amount | 17083.46 |
| Total Medical Medicare Standardized Payment Amount | 21577.1 |
| Average Age Of Beneficiaries | 65 |
| Number Of Beneficiaries Age Less65 | 59 |
| Number Of Beneficiaries Age 65 to 74 | 72 |
| Number Of Beneficiaries Age 75 to 84 | |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 58 |
| Number Of Male Beneficiaries | 94 |
| Number Of Non Hispanic White Beneficiaries | 127 |
| Number Of Black or African American Beneficiaries | 12 |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | |
| Number Of American Indian Alaska Native Beneficiaries | 0 |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 123 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 29 |
| Percent Of With Atrial Fibrillation | 9 |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | |
| Percent Of With Cancer | 7 |
| Percent Of With Heart Failure | 19 |
| Percent Of With Chronic Kidney Disease | 55 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 11 |
| Percent Of With Depression | 29 |
| Percent Of With Diabetes | 54 |
| Percent Of With Hyperlipidemia | 36 |
| Percent Of With Hypertension | 66 |
| Percent Of With Ischemic Heart Disease | 36 |
| Percent Of With Osteoporosis | 9 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 55 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 2.6736 |