Healthcare Provider Details

I. General information

NPI: 1851202295
Provider Name (Legal Business Name): TYSHAN D BLACK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: TYSHAN SANCHEZ BLACK

II. Dates (important events)

Enumeration Date: 09/15/2026
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2837 LYNDALE AVE S
MINNEAPOLIS MN
55408-2109
US

IV. Provider business mailing address

7810 IDAHO LN N
BROOKLYN PARK MN
55445-2712
US

V. Phone/Fax

Practice location:
  • Phone: 612-872-9596
  • Fax:
Mailing address:
  • Phone: 612-670-0437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: