| National Provider Identifier [NPI]: | 1972683753 |
| Last Name Of The Provider | MORTENSEN |
| First Name Of The Provider | THERESA |
| Middle Initial Of The Provider | L |
| Credentials Of The Provider | N.P. |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 3555 ROUND BARN CIR |
| Street Address 2 Of The Provider | |
| City Of The Provider | SANTA ROSA |
| Zip Code Of The Provider | 954031757 |
| State Code Of The Provider | CA |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Nurse Practitioner |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 34 |
| Number Of Services | 1890 |
| Number Of Medicare Beneficiaries | 87 |
| Total Submitted Charge Amount | 63330 |
| Total Medicare Allowed Amount | 25222.19 |
| Total Medicare Payment Amount | 19797.3 |
| Total Medicare Standardized Payment Amount | 20318.54 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 13 |
| Number Of Drug Services | 1734 |
| Number Of Medicare Beneficiaries With Drug Services | 15 |
| Total Drug Submitted ChargeAmount | 47658 |
| Total Drug Medicare AllowedAmount | 18289.94 |
| Total Drug Medicare PaymentAmount | 14337.63 |
| Total Drug Medicare Standardized Payment Amount | 14337.63 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 21 |
| Number Of Medical Services | 156 |
| Number Of Medicare Beneficiaries With Medical Services | 87 |
| Total Medical Submitted Charge Amount | 15672 |
| Total Medical Medicare Allowed Amount | 6932.25 |
| Total Medical Medicare Payment Amount | 5459.67 |
| Total Medical Medicare Standardized Payment Amount | 5980.91 |
| Average Age Of Beneficiaries | 78 |
| Number Of Beneficiaries Age Less65 | |
| Number Of Beneficiaries Age 65 to 74 | 26 |
| Number Of Beneficiaries Age 75 to 84 | 35 |
| Number Of Beneficiaries Age Greater 84 | |
| Number Of Female Beneficiaries | 48 |
| Number Of Male Beneficiaries | 39 |
| Number Of Non Hispanic White Beneficiaries | 75 |
| 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 | 73 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 14 |
| Percent Of With Atrial Fibrillation | 14 |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | |
| Percent Of With Cancer | 38 |
| Percent Of With Heart Failure | 36 |
| Percent Of With Chronic Kidney Disease | 33 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 21 |
| Percent Of With Depression | 28 |
| Percent Of With Diabetes | 28 |
| Percent Of With Hyperlipidemia | 56 |
| Percent Of With Hypertension | 71 |
| Percent Of With Ischemic Heart Disease | 54 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 47 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 2.2925 |