| National Provider Identifier [NPI]: | 1780992024 |
| Last Name Of The Provider | GANNON |
| First Name Of The Provider | TIM |
| Middle Initial Of The Provider | B |
| Credentials Of The Provider | P.A. |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 3450 ZAFARANO DR |
| Street Address 2 Of The Provider | SUITE C |
| City Of The Provider | SANTA FE |
| Zip Code Of The Provider | 875072669 |
| State Code Of The Provider | NM |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Physician Assistant |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 40 |
| Number Of Services | 334 |
| Number Of Medicare Beneficiaries | 195 |
| Total Submitted Charge Amount | 46242.97 |
| Total Medicare Allowed Amount | 19748.56 |
| Total Medicare Payment Amount | 12697.51 |
| Total Medicare Standardized Payment Amount | 16325.78 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 9 |
| Number Of Drug Services | 36 |
| Number Of Medicare Beneficiaries With Drug Services | 17 |
| Total Drug Submitted ChargeAmount | 949 |
| Total Drug Medicare AllowedAmount | 234.04 |
| Total Drug Medicare PaymentAmount | 213.7 |
| Total Drug Medicare Standardized Payment Amount | 213.7 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 31 |
| Number Of Medical Services | 298 |
| Number Of Medicare Beneficiaries With Medical Services | 195 |
| Total Medical Submitted Charge Amount | 45293.97 |
| Total Medical Medicare Allowed Amount | 19514.52 |
| Total Medical Medicare Payment Amount | 12483.81 |
| Total Medical Medicare Standardized Payment Amount | 16112.08 |
| Average Age Of Beneficiaries | 68 |
| Number Of Beneficiaries Age Less65 | 47 |
| Number Of Beneficiaries Age 65 to 74 | 88 |
| Number Of Beneficiaries Age 75 to 84 | 44 |
| Number Of Beneficiaries Age Greater 84 | 16 |
| Number Of Female Beneficiaries | 125 |
| Number Of Male Beneficiaries | 70 |
| Number Of Non Hispanic White Beneficiaries | 104 |
| 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 | 152 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 43 |
| Percent Of With Atrial Fibrillation | |
| Percent Of With Alzheimers Disease or Dementia | |
| Percent Of With Asthma | 9 |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | 6 |
| Percent Of With Chronic Kidney Disease | 17 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 12 |
| Percent Of With Depression | 19 |
| Percent Of With Diabetes | 21 |
| Percent Of With Hyperlipidemia | 37 |
| Percent Of With Hypertension | 45 |
| Percent Of With Ischemic Heart Disease | 13 |
| Percent Of With Osteoporosis | 7 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 29 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 0.8565 |