Healthcare Provider Details

I. General information

NPI: 1437747821
Provider Name (Legal Business Name): CANAAN MEKONNEN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/01/2021
Last Update Date: 09/30/2025
Certification Date: 09/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15215 SHADY GROVE RD STE 100
ROCKVILLE MD
20850-3235
US

IV. Provider business mailing address

15215 SHADY GROVE RD STE 100
ROCKVILLE MD
20850-3235
US

V. Phone/Fax

Practice location:
  • Phone: 240-506-0530
  • Fax:
Mailing address:
  • Phone: 240-506-0530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0007774
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA67008
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: