Healthcare Provider Details

I. General information

NPI: 1336195973
Provider Name (Legal Business Name): GRANWEL GENIO ESTEBAN JR. PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 07/28/2021
Certification Date: 07/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1114 W MADISON AVE
ATHENS TN
37303-4150
US

IV. Provider business mailing address

PO BOX 634760
CINCINNATI OH
45263-0001
US

V. Phone/Fax

Practice location:
  • Phone: 423-745-1411
  • Fax: 865-539-8008
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number02673-01
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA1004
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: