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General NPI Number Information
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NPI Number | 1851202295
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Entity Type | Individual
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Provider Name | TYSHAN D BLACK
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Gender | Male
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Dates
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Enumeration Date | 09/15/2026
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Last Update Date | 09/15/2026
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Provider Practice Location Address
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Address Line | 2837 LYNDALE AVE S
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City | MINNEAPOLIS
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State | MN
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Zip | 55408-2109
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Country | US
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Telephone | 612-872-9596
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Fax |
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Provider Business Mailing Address
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Address Line | 7810 IDAHO LN N
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City | BROOKLYN PARK
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State | MN
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Zip | 55445-2712
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Country | US
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Telephone | 612-670-0437
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number |
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License Number State | MN
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