| National Provider Identifier [NPI]: | 1609865203 |
| Last Name Of The Provider | LARSEN |
| First Name Of The Provider | DALLEN |
| Middle Initial Of The Provider | J |
| Credentials Of The Provider | PA |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 4650 HARRISON BLVD |
| Street Address 2 Of The Provider | |
| City Of The Provider | OGDEN |
| Zip Code Of The Provider | 844034303 |
| State Code Of The Provider | UT |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Physician Assistant |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 80 |
| Number Of Services | 970 |
| Number Of Medicare Beneficiaries | 231 |
| Total Submitted Charge Amount | 57781 |
| Total Medicare Allowed Amount | 31608.51 |
| Total Medicare Payment Amount | 22759.19 |
| Total Medicare Standardized Payment Amount | 27494.68 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 13 |
| Number Of Drug Services | 134 |
| Number Of Medicare Beneficiaries With Drug Services | 40 |
| Total Drug Submitted ChargeAmount | 2466 |
| Total Drug Medicare AllowedAmount | 643.8 |
| Total Drug Medicare PaymentAmount | 555.71 |
| Total Drug Medicare Standardized Payment Amount | 555.71 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 67 |
| Number Of Medical Services | 836 |
| Number Of Medicare Beneficiaries With Medical Services | 231 |
| Total Medical Submitted Charge Amount | 55315 |
| Total Medical Medicare Allowed Amount | 30964.71 |
| Total Medical Medicare Payment Amount | 22203.48 |
| Total Medical Medicare Standardized Payment Amount | 26938.97 |
| Average Age Of Beneficiaries | 73 |
| Number Of Beneficiaries Age Less65 | 21 |
| Number Of Beneficiaries Age 65 to 74 | 115 |
| Number Of Beneficiaries Age 75 to 84 | 66 |
| Number Of Beneficiaries Age Greater 84 | 29 |
| Number Of Female Beneficiaries | 130 |
| Number Of Male Beneficiaries | 101 |
| Number Of Non Hispanic White Beneficiaries | 197 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | 0 |
| Number Of Hispanic Beneficiaries | 23 |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 213 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 18 |
| Percent Of With Atrial Fibrillation | 6 |
| Percent Of With Alzheimers Disease or Dementia | 11 |
| Percent Of With Asthma | 8 |
| Percent Of With Cancer | 10 |
| Percent Of With Heart Failure | 13 |
| Percent Of With Chronic Kidney Disease | 17 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 9 |
| Percent Of With Depression | 22 |
| Percent Of With Diabetes | 23 |
| Percent Of With Hyperlipidemia | 34 |
| Percent Of With Hypertension | 53 |
| Percent Of With Ischemic Heart Disease | 24 |
| Percent Of With Osteoporosis | 7 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 36 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 0.8996 |