| National Provider Identifier [NPI]: | 1235427816 |
| Last Name Of The Provider | COULIBALY |
| First Name Of The Provider | SURURAT |
| Middle Initial Of The Provider | A |
| Credentials Of The Provider | PA-C |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 2316 W CHARLESTON BLVD |
| Street Address 2 Of The Provider | ADULT MEDICINE CLINIC |
| City Of The Provider | LAS VEGAS |
| Zip Code Of The Provider | 891022149 |
| State Code Of The Provider | NV |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Physician Assistant |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 53 |
| Number Of Services | 363 |
| Number Of Medicare Beneficiaries | 181 |
| Total Submitted Charge Amount | 37957 |
| Total Medicare Allowed Amount | 16559.18 |
| Total Medicare Payment Amount | 11692.61 |
| Total Medicare Standardized Payment Amount | 13538.9 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 12 |
| Number Of Drug Services | 55 |
| Number Of Medicare Beneficiaries With Drug Services | 20 |
| Total Drug Submitted ChargeAmount | 802 |
| Total Drug Medicare AllowedAmount | 52.28 |
| Total Drug Medicare PaymentAmount | 38.6 |
| Total Drug Medicare Standardized Payment Amount | 38.6 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 41 |
| Number Of Medical Services | 308 |
| Number Of Medicare Beneficiaries With Medical Services | 181 |
| Total Medical Submitted Charge Amount | 37155 |
| Total Medical Medicare Allowed Amount | 16506.9 |
| Total Medical Medicare Payment Amount | 11654.01 |
| Total Medical Medicare Standardized Payment Amount | 13500.3 |
| Average Age Of Beneficiaries | 71 |
| Number Of Beneficiaries Age Less65 | 29 |
| Number Of Beneficiaries Age 65 to 74 | 83 |
| Number Of Beneficiaries Age 75 to 84 | 51 |
| Number Of Beneficiaries Age Greater 84 | 18 |
| Number Of Female Beneficiaries | 104 |
| Number Of Male Beneficiaries | 77 |
| Number Of Non Hispanic White Beneficiaries | 128 |
| Number Of Black or African American Beneficiaries | 18 |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 17 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 145 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 36 |
| Percent Of With Atrial Fibrillation | 9 |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | 10 |
| Percent Of With Cancer | 10 |
| Percent Of With Heart Failure | 13 |
| Percent Of With Chronic Kidney Disease | 28 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 13 |
| Percent Of With Depression | 11 |
| Percent Of With Diabetes | 27 |
| Percent Of With Hyperlipidemia | 52 |
| Percent Of With Hypertension | 65 |
| Percent Of With Ischemic Heart Disease | 23 |
| Percent Of With Osteoporosis | 6 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 40 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.0015 |