Individual
MR. GRANWEL GENIO ESTEBAN JR.
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA
Contact information
Practice address
1114 W MADISON AVE, ATHENS, TN 37303-4150
(423) 745-1411
(865) 539-8008
Mailing address
PO BOX 634760, CINCINNATI, OH 45263-0001
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
02673-01
NY
363A00000X
Physician Assistant
Primary
PA1004
TN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
009941923
—
AL
01
—
4061134
BLUE CROSS
TN
05
—
587885291A
—
GA
05
—
891012540
—
AL
01
—
P00001071
RAILROAD MEDICARE
TN
Enumeration date
05/25/2006
Last updated
07/28/2021
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