Provider Demographics
NPI:1538826581
Name:GIBSON, TRENT CONNER
Entity type:Individual
Prefix:
First Name:TRENT
Middle Name:CONNER
Last Name:GIBSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4841 COLONY CHURCH RD APT 3
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63129-1151
Mailing Address - Country:US
Mailing Address - Phone:314-262-0312
Mailing Address - Fax:
Practice Address - Street 1:1 MERAMEC BLUFFS DR
Practice Address - Street 2:
Practice Address - City:BALLWIN
Practice Address - State:MO
Practice Address - Zip Code:63021-3309
Practice Address - Country:US
Practice Address - Phone:636-861-0600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-24
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015024305225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant