Provider Demographics
NPI:1992095798
Name:ETHIER, WAYNE (MSN, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:
Last Name:ETHIER
Suffix:
Gender:M
Credentials:MSN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 LIBERTY SQ STE 91234
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-5800
Mailing Address - Country:US
Mailing Address - Phone:508-422-0404
Mailing Address - Fax:
Practice Address - Street 1:5 RICHFIELD CIR
Practice Address - Street 2:
Practice Address - City:CARVER
Practice Address - State:MA
Practice Address - Zip Code:02330-1902
Practice Address - Country:US
Practice Address - Phone:508-422-0404
Practice Address - Fax:508-422-0404
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-13
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2314626363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health