Healthcare Provider Details

I. General information

NPI: 1619239613
Provider Name (Legal Business Name): RANDI SESSOMS LASSITER GREEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2012
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 RIVERSIDE AVE
MINNEAPOLIS MN
55454-1450
US

IV. Provider business mailing address

2450 RIVERSIDE AVE
MINNEAPOLIS MN
55454-1450
US

V. Phone/Fax

Practice location:
  • Phone: 612-626-4214
  • Fax: 612-624-6969
Mailing address:
  • Phone: 612-626-4214
  • Fax: 612-624-6969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number70005
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberME140972
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number184335
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberBM6733807-Q141
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: