Provider Demographics
NPI:1063152791
Name:JOHNSRUD, DAVID LARS CHRISTIAN (BA, MAC, BSN)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:LARS CHRISTIAN
Last Name:JOHNSRUD
Suffix:
Gender:M
Credentials:BA, MAC, BSN
Other - Prefix:
Other - First Name:KAREN
Other - Middle Name:CHRISTIANE
Other - Last Name:JOHNSRUDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BA, MAC, BSN
Mailing Address - Street 1:3841 N COUNTRY CLUB RD UNIT 2
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85716-1011
Mailing Address - Country:US
Mailing Address - Phone:520-225-9785
Mailing Address - Fax:
Practice Address - Street 1:1002 15TH ST SW
Practice Address - Street 2:MAILSTOP 1002-1-TRI
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98001-9841
Practice Address - Country:US
Practice Address - Phone:520-225-9785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-30
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60607354163WP2201X
AZRNP289863363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care