Provider Demographics
NPI:1043264492
Name:KANNO, METTASSEBIA (MD)
Entity Type:Individual
Prefix:MS
First Name:METTASSEBIA
Middle Name:
Last Name:KANNO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 E JEFFERSON ST
Mailing Address - Street 2:KAISER PERMANENTE MEDICARE ENROLLMENT
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-2424
Mailing Address - Fax:
Practice Address - Street 1:10 HOPKINS PLZ
Practice Address - Street 2:KAISER PERMANENTE CITY PLAZA MEDICAL CENTER
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-2900
Practice Address - Country:US
Practice Address - Phone:443-263-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA237156207R00000X
MDD58251207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1043264492Medicaid
MD395000000Medicaid
MD617124-01OtherBLUE CROSS/BLUE SHIELD
H63614Medicare UPIN
DE1043264492Medicaid