Provider Demographics
NPI:1538963947
Name:FAVRE, MASON LAROSA (MD)
Entity type:Individual
Prefix:
First Name:MASON
Middle Name:LAROSA
Last Name:FAVRE
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 WYNDHAM CV
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-1426
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:920 MADISON AVE STE 4427
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-3438
Practice Address - Country:US
Practice Address - Phone:901-759-3275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-03
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program