Basic Information
| Provider Information | |||||||||
| NPI: | 1336195973 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ESTEBAN | ||||||||
| FirstName: | GRANWEL | ||||||||
| MiddleName: | GENIO | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 634760 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452630001 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1114 W MADISON AVE | ||||||||
| Address2: | |||||||||
| City: | ATHENS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373034150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237451411 | ||||||||
| FaxNumber: | 8655398008 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 07/28/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 02673-01 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA1004 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 009941923 | 05 | AL | MEDICAID | 587885291A | 05 | GA | MEDICAID | 4061134 | 01 | TN | BLUE CROSS | OTHER | 891012540 | 05 | AL | MEDICAID | P00001071 | 01 | TN | RAILROAD MEDICARE | OTHER |