| National Provider Identifier [NPI]: | 1912981341 |
| Last Name Of The Provider | THEOBALD |
| First Name Of The Provider | MICHELLE |
| Middle Initial Of The Provider | L |
| Credentials Of The Provider | PA-C |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 6405 FRANCE AVE S # SW200 |
| Street Address 2 Of The Provider | |
| City Of The Provider | EDINA |
| Zip Code Of The Provider | 554352163 |
| State Code Of The Provider | MN |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Physician Assistant |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 19 |
| Number Of Services | 372 |
| Number Of Medicare Beneficiaries | 159 |
| Total Submitted Charge Amount | 54427.75 |
| Total Medicare Allowed Amount | 21507.75 |
| Total Medicare Payment Amount | 15780.2 |
| Total Medicare Standardized Payment Amount | 19307.73 |
| Drug Suppress Indicator | * |
| Number Of HCPCS Associated With Drug Services | |
| Number Of Drug Services | |
| Number Of Medicare Beneficiaries With Drug Services | |
| Total Drug Submitted ChargeAmount | |
| Total Drug Medicare AllowedAmount | |
| Total Drug Medicare PaymentAmount | |
| Total Drug Medicare Standardized Payment Amount | |
| Medical SuppressIndicator | # |
| Number Of HCPCS Associated With MedicalServices | |
| Number Of Medical Services | |
| Number Of Medicare Beneficiaries With Medical Services | |
| Total Medical Submitted Charge Amount | |
| Total Medical Medicare Allowed Amount | |
| Total Medical Medicare Payment Amount | |
| Total Medical Medicare Standardized Payment Amount | |
| Average Age Of Beneficiaries | 78 |
| Number Of Beneficiaries Age Less65 | |
| Number Of Beneficiaries Age 65 to 74 | 42 |
| Number Of Beneficiaries Age 75 to 84 | 71 |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 74 |
| Number Of Male Beneficiaries | 85 |
| Number Of Non Hispanic White Beneficiaries | |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 143 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 16 |
| Percent Of With Atrial Fibrillation | 50 |
| Percent Of With Alzheimers Disease or Dementia | 13 |
| Percent Of With Asthma | 9 |
| Percent Of With Cancer | 12 |
| Percent Of With Heart Failure | 52 |
| Percent Of With Chronic Kidney Disease | 40 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 16 |
| Percent Of With Depression | 16 |
| Percent Of With Diabetes | 28 |
| Percent Of With Hyperlipidemia | 55 |
| Percent Of With Hypertension | 74 |
| Percent Of With Ischemic Heart Disease | 65 |
| Percent Of With Osteoporosis | 9 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 35 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 1.7185 |