Healthcare Provider Details

I. General information

NPI: 1639017940
Provider Name (Legal Business Name): ANTHONY MATTROX HERSOM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2026
Last Update Date: 03/25/2026
Certification Date: 03/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 S MAIN ST STE 2
BISHOP CA
93514-3415
US

IV. Provider business mailing address

4005 ERSKINE CREEK RD
LAKE ISABELLA CA
93240-9585
US

V. Phone/Fax

Practice location:
  • Phone: 760-614-1157
  • Fax:
Mailing address:
  • Phone: 760-608-3845
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: