SOUPHAPHONE BOUNMYTHAVONG NICKSIC (CRNA) – Certified Registered Nurse Anesthetist, NPI 1740425701
Certified Registered Nurse Anesthetist
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Profile Insights
NPPES metrics only — not quality of care.
2,265 CERTIFIED REGISTERED NURSE ANESTHETIST (CRNA) in IL
Provider Addresses for SOUPHAPHONE BOUNMYTHAVONG NICKSIC (CRNA)
2475 Dean St
Saint Charles, IL 601754831
Phone: (630) 584-9800
Type: Location
2600 Greenbush St
Lafayette, IN 479042477
Phone: (765) 448-8000
Type: Location
Prophetstown Aquatic Center, 5545, Swisher Road, West Lafayette, Tippecanoe County, Indiana, 47906, United States
LAFAYETTE, IN 479035545
Phone: (765) 448-8000
Type: Mailing
2600, Greenbush Street, Eastwich, Lafayette, Tippecanoe County, Indiana, 47904, United States
LAFAYETTE, IN 479042477
Phone: (765) 448-8000
Type: Location
2475 DEAN ST
SAINT CHARLES, IL 601754831
Phone: (630) 584-9800
Type: Mailing
29373 NETWORK PL
CHICAGO, IL 606731293
Phone: (847) 390-5900
Type: Mailing
1425 N RANDALL RD
ELGIN, IL 601232300
Phone: (224) 783-1065
Fax: (224) 783-2852
Type: Location
NPPES updates history
No NPPES updates recorded for this provider.
Prescription Activity
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Open Payments (CMS)
CMS reports 2 Open Payments records for all available years, with a total value of $112.
Total Amount is formed as General ($112) + Research ($0) + Ownership ($0) = $112.
Last reported payment date: 2023-05-30 • Largest payer in this snapshot: Edwards Lifesciences Corporation ($112).
Total Amount
$112
General + Research + Ownership
Payments
2
Total payment records
General Amount
$112
General payments
Research Amount
$0
Research funding
Ownership Amount
$0
Ownership interests
Ownership Count
0
Ownership records
Last Payment Date
2023-05-30
Latest reported date
Top Companies
Largest payers in this snapshot
| Company | Amount |
|---|---|
| Edwards Lifesciences Corporation | $112 |
Medicare Enrollment & Revalidation
Source: CMS public data · Not endorsed by CMS ·
Educational use only—not medical, billing, or legal advice.
PECOS enrollment status
Participating (accepts Medicare assignment)
Enrollment effective: 2012-03-23
PECOS data refreshed: 2026-05-27
Medicare revalidation (CMS due date list)
Due date not assigned yet
CMS is tracking this Medicare enrollment for revalidation, but has not published a due date.
Enrollment records
1
Earliest due date
Not assigned (TBD)
CMS data updated
2026-06-01
Revalidation progress
- Medicare enrolled
- On CMS revalidation list
- Due date assigned
- Revalidate in PECOS
CMS enrollment records
| Enrollment ID | Type | Specialty | State | Due date |
|---|---|---|---|---|
| I20120323000591 | I | Certified Registered Nurse Anesthetist (Crna) | IL | TBD |
What to do next
- No action required while the due date shows TBD.
- Check the CMS Revalidation Lookup Tool periodically — CMS updates the list about every 60 days.
- Do not submit a revalidation application in PECOS until CMS publishes a concrete due date.
Prepare CMS-855 application → · Look up this NPI in PECOS → · Verify on CMS PECOS
Medicare Utilization (FFS)
Source: CMS public data · Not endorsed by CMS · Beneficiary counts under 11 are suppressed in source data ·
Educational use only—not medical, billing, or legal advice.
Top Medicare procedures (2023) · refreshed 2026-05-27
| HCPCS | Description | Services | Beneficiaries | Medicare allowed |
|---|---|---|---|---|
| 00142 | Anesthesia for lens surgery | 33 | 33 | $0 |
| 00812 | Anesthesia for exam of colon using an endoscope | 14 | 14 | $0 |
Insurance plans in this area (ZIP 60175)
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Group practice members
| Name | Specialty | State |
|---|---|---|
| Nephrology, Internal Medicine | IL | |
| A N E S T H E S I O L O G Y | IL | |
| - | MN | |
| - | IL | |
| - | IL | |
| Rheumatology, Internal Medicine | IL | |
| - | IL | |
| Internal Medicine | IL | |
| P S Y C H I A T R Y | IL | |
| - | IL |
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