Healthcare Provider Details

I. General information

NPI: 1245731322
Provider Name (Legal Business Name): HARLEY DAKIS SFIDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2018
Last Update Date: 12/13/2025
Certification Date: 12/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34800 BOB WILSON DRIVE
SAN DIEGO CA
92134-1098
US

IV. Provider business mailing address

34101 FARENHOLT AVE BLDG 14
SAN DIEGO CA
92134-5291
US

V. Phone/Fax

Practice location:
  • Phone: 619-532-6400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: