Provider Demographics
NPI:1053149831
Name:ABRAXAS SCIENTIFIC
Entity type:Organization
Organization Name:ABRAXAS SCIENTIFIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LABORATORY DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:VADIM
Authorized Official - Middle Name:
Authorized Official - Last Name:YEROKHIN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:918-917-4321
Mailing Address - Street 1:1728 S CARSON AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74119-4610
Mailing Address - Country:US
Mailing Address - Phone:918-917-4321
Mailing Address - Fax:
Practice Address - Street 1:1728 S CARSON AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74119-4610
Practice Address - Country:US
Practice Address - Phone:918-917-4321
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THERAPEUTIC LIFE CHOICES TOHI USTI GVNVNV EDASDI LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-07-23
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK37D2301589Medicaid