| National Provider Identifier [NPI]: | 1588932495 |
| Last Name Of The Provider | PHOLSENA |
| First Name Of The Provider | THEPTHARA |
| Middle Initial Of The Provider | N |
| Credentials Of The Provider | |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 17707 W MAIN ST |
| Street Address 2 Of The Provider | 1ST FL |
| City Of The Provider | MONROE |
| Zip Code Of The Provider | 982721967 |
| State Code Of The Provider | WA |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Nurse Practitioner |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 26 |
| Number Of Services | 156 |
| Number Of Medicare Beneficiaries | 48 |
| Total Submitted Charge Amount | 3158.49 |
| Total Medicare Allowed Amount | 2236.14 |
| Total Medicare Payment Amount | 2020.28 |
| Total Medicare Standardized Payment Amount | 2183.24 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 5 |
| Number Of Drug Services | 17 |
| Number Of Medicare Beneficiaries With Drug Services | 15 |
| Total Drug Submitted ChargeAmount | 662.83 |
| Total Drug Medicare AllowedAmount | 661.49 |
| Total Drug Medicare PaymentAmount | 648.22 |
| Total Drug Medicare Standardized Payment Amount | 648.22 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 21 |
| Number Of Medical Services | 139 |
| Number Of Medicare Beneficiaries With Medical Services | 47 |
| Total Medical Submitted Charge Amount | 2495.66 |
| Total Medical Medicare Allowed Amount | 1574.65 |
| Total Medical Medicare Payment Amount | 1372.06 |
| Total Medical Medicare Standardized Payment Amount | 1535.02 |
| Average Age Of Beneficiaries | 60 |
| Number Of Beneficiaries Age Less65 | 25 |
| Number Of Beneficiaries Age 65 to 74 | |
| Number Of Beneficiaries Age 75 to 84 | |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 33 |
| Number Of Male Beneficiaries | 15 |
| Number Of Non Hispanic White Beneficiaries | 35 |
| Number Of Black or African American Beneficiaries | |
| 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 | 19 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 29 |
| Percent Of With Atrial Fibrillation | |
| 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 | 23 |
| Percent Of With Diabetes | 38 |
| Percent Of With Hyperlipidemia | 33 |
| Percent Of With Hypertension | 48 |
| Percent Of With Ischemic Heart Disease | |
| Percent Of With Osteoporosis | 0 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 25 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 0.9547 |