Provider Demographics
NPI:1336195973
Name:ESTEBAN, GRANWEL GENIO JR (PA)
Entity Type:Individual
Prefix:MR
First Name:GRANWEL
Middle Name:GENIO
Last Name:ESTEBAN
Suffix:JR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 634760
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1114 W MADISON AVE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TN
Practice Address - Zip Code:37303-4150
Practice Address - Country:US
Practice Address - Phone:423-745-1411
Practice Address - Fax:865-539-8008
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY02673-01363A00000X
TNPA1004363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009941923Medicaid
GA587885291AMedicaid
TN4061134OtherBLUE CROSS
AL891012540Medicaid
TNP00001071OtherRAILROAD MEDICARE
TN103I970594Medicare PIN
TNP00001071OtherRAILROAD MEDICARE
TN103I978621Medicare PIN
TN3661415Medicare PIN