Provider Demographics
NPI:1679163877
Name:GRANT, TYLER (DO)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:GRANT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1624 HARMON PL STE 209
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55403-1902
Mailing Address - Country:US
Mailing Address - Phone:941-203-9408
Mailing Address - Fax:
Practice Address - Street 1:1624 HARMON PL STE 209
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55403-1902
Practice Address - Country:US
Practice Address - Phone:941-203-9408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-21
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLIC390595225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist