Provider Demographics
NPI:1568118263
Name:ROBERTSON, QUINN DAVID
Entity Type:Individual
Prefix:
First Name:QUINN
Middle Name:DAVID
Last Name:ROBERTSON
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 1:4770 W CARLA VISTA DR
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85226-2915
Mailing Address - Country:US
Mailing Address - Phone:602-568-2418
Mailing Address - Fax:
Practice Address - Street 1:715 S 9TH ST
Practice Address - Street 2:
Practice Address - City:CANON CITY
Practice Address - State:CO
Practice Address - Zip Code:81212-4911
Practice Address - Country:US
Practice Address - Phone:719-269-8820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-22
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0007192363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant