| National Provider Identifier [NPI]: | 1083907679 |
| Last Name Of The Provider | WILLIS |
| First Name Of The Provider | PARK |
| Middle Initial Of The Provider | W |
| Credentials Of The Provider | M.D. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 1250 E 3900 S |
| Street Address 2 Of The Provider | SUITE 260 |
| City Of The Provider | SALT LAKE CITY |
| Zip Code Of The Provider | 841241348 |
| State Code Of The Provider | UT |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 40 |
| Number Of Services | 258 |
| Number Of Medicare Beneficiaries | 135 |
| Total Submitted Charge Amount | 20966 |
| Total Medicare Allowed Amount | 13518.79 |
| Total Medicare Payment Amount | 10160.83 |
| Total Medicare Standardized Payment Amount | 10607.21 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 9 |
| Number Of Drug Services | 61 |
| Number Of Medicare Beneficiaries With Drug Services | 14 |
| Total Drug Submitted ChargeAmount | 608 |
| Total Drug Medicare AllowedAmount | 167.28 |
| Total Drug Medicare PaymentAmount | 131.14 |
| Total Drug Medicare Standardized Payment Amount | 131.14 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 31 |
| Number Of Medical Services | 197 |
| Number Of Medicare Beneficiaries With Medical Services | 135 |
| Total Medical Submitted Charge Amount | 20358 |
| Total Medical Medicare Allowed Amount | 13351.51 |
| Total Medical Medicare Payment Amount | 10029.69 |
| Total Medical Medicare Standardized Payment Amount | 10476.07 |
| Average Age Of Beneficiaries | 72 |
| Number Of Beneficiaries Age Less65 | 21 |
| Number Of Beneficiaries Age 65 to 74 | 49 |
| Number Of Beneficiaries Age 75 to 84 | 38 |
| Number Of Beneficiaries Age Greater 84 | 27 |
| Number Of Female Beneficiaries | 88 |
| Number Of Male Beneficiaries | 47 |
| Number Of Non Hispanic White Beneficiaries | 119 |
| 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 | 117 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 18 |
| Percent Of With Atrial Fibrillation | |
| Percent Of With Alzheimers Disease or Dementia | 10 |
| Percent Of With Asthma | 10 |
| Percent Of With Cancer | 10 |
| Percent Of With Heart Failure | 10 |
| Percent Of With Chronic Kidney Disease | 13 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 10 |
| Percent Of With Depression | 25 |
| Percent Of With Diabetes | 24 |
| Percent Of With Hyperlipidemia | 32 |
| Percent Of With Hypertension | 53 |
| Percent Of With Ischemic Heart Disease | 25 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 44 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.0132 |