Provider Demographics
NPI:1487033650
Name:MWANSA, PEARL DIANA (MD)
Entity Type:Individual
Prefix:
First Name:PEARL
Middle Name:DIANA
Last Name:MWANSA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PEARL
Other - Middle Name:DIANA
Other - Last Name:BEKALO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2900 SAINT MICHAEL DR STE 401
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-5211
Mailing Address - Country:US
Mailing Address - Phone:903-614-5383
Mailing Address - Fax:903-614-5343
Practice Address - Street 1:2606 HOSPITAL BLVD STE B
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78405
Practice Address - Country:US
Practice Address - Phone:361-902-4789
Practice Address - Fax:361-902-4588
Is Sole Proprietor?:No
Enumeration Date:2015-05-21
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10054275390200000X
TXR3719207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP02601796OtherMCRR
TX395038802Medicaid
TX1L5069OtherMEDICARE